SINH L HC V MU i. i cng Mu c tim bm vo h thng mch mu v i khp c th.

Trong cng tc chm sc sc kho, mu c bit c quan tm v c nhiu xt nghim chn on c thc hin trn mu. Mu c cu to bi huyt tng v thnh phn hu hnh. Huyt tng l thnh phn dch chim 55-60%. Huyt tng gm nc v cc cht ho tan, trong ch yu l cc loi protein, ngoi ra cn c cc cht in gii, cht dinh dng, enzym, hormon, kh v cc cht thi. Thnh phn hu hnh chim 40-45%, gm hng cu, bch cu v tiu cu. S hin din ca cc thnh phn hu hnh v protein lm mu c qunh gp nm ln so vi nc. Mu c pH khong 7,35-7,4, ty thuc vo lng CO2 trong mu. V khi lng, mu chim khong 8% so vi ton c th. Mu lu thng trong h mch v c ba chc nng chnh nh sau: Vn chuyn - Mu vn chuyn kh O2 v kh CO2. - Vn chuyn cht dinh dng, cc sn phm o thi. - Vn chuyn hormon t tuyn ni tit n cc t bo ch. - Ngoi ra mu cn vn chuyn nhit. 2. Bo v - Mu c th chng li cc vi sinh vt gy bnh v cc c t. - C th chng mt mu khi tn thng thnh mch nh qu trnh cm mu. 3. iu ho - Mu tham gia iu ho pH ni mi thng qua h thng m ca n. - iu ho lng nc trong t bo thng qua p sut thm thu keo ca mu. - Mu cn tham gia iu nhit. II. Qu trnh to mu 1. C quan to mu Trong sut thi k phi thai, ln lt ti non hong, gan, lch, tuyn c, hch bch huyt v tu xng tham gia hnh thnh cc t bo mu. Tuy nhin, sau khi sinh qu trnh to mu ch xy ra tu xng. Di 5 tui, tu ca tt c cc loi xng u l tu , ngha l u c kh nng to mu. Sau la tui ny, cc tu xng di (tr hai u xng cnh tay v xng i) b m xm ln dn v t tui hai mi tr i chng hon ton tr thnh tu vng khng tham gia to mu na. Nh vy sau 20 tui, ch c tu xng dt v hai u xng i, hai u xng cnh tay tham gia to mu. Tu xng cha cc t bo gc to mu a nng (pluripotential hemopoietic stem cell). Cc t bo ny sinh sn lin tc trong sut cuc i. Mt phn nh s c gi li nh l cc t bo ngun, tuy rng s lng s gim dn theo tui. Phn ln c bit ho thnh cc t bo mu khc nhau. 2. Qu trnh bit ho Cc t bo gc to mu a nng c bit ho thnh cc loi t bo gc bit ho (committed stem cell). Qu trnh sinh sn v bit ho tip tc to thnh mi loi t bo mu s din ra qua nhiu giai on (xem hnh 1). Cc qu trnh ny cn s tham gia ca cc cht kch thch khc nhau nh: - Erythropoietin (EPO): kch thch to hng cu - Thrombopoietin (TPO): kch thch to tiu cu - Cc yu t kch thch to cm (CSFs: colony-stimulating factors) v cc interleukin (IL): kch thch to bch cu, ring IL-3 c tc dng tng sinh sn tt c cc loi t bo gc. - Yu t t bo gc (SCF: stem cell factor): kch thch s sinh sn ca cc t bo gc bit ho, n c hiu qu ln nhiu dng t bo. 1.

III. Hng cu 1. Hnh dng - cu trc Hng cu chim hn 99% trong cc thnh phn hu hnh ca mu. l nhng t bo c hnh a hai mt lm, ng knh 7-8 mm, b dy phn ngoi vi 2-2,5 mm v phn trung tm 1 mm, th tch trung bnh 90-95 mm3. Hnh dng ny c hai li im nh sau: - Tng din tch b mt tip xc lm tng kh nng khuch tn kh thm 30% so vi hng cu cng th tch m c dng hnh cu. - Lm cho hng cu tr nn cc k mm do, c th i qua cc mao mch hp m khng gy tn thng mao mch cng nh bn thn hng cu. Hng cu khng c nhn cng nh cc bo quan. Thnh phn chnh ca hng cu l hemoglobin (Hb), chim 34% trng lng (nng 34 g/dl trong dch bo tng). Cu trc ca hng cu c bit thch ng vi chc nng vn chuyn kh oxy. 2. S lng ngi bnh thng, s lng hng cu trong mu ngoi vi l: Nam: 5.400.000 300.000 /mm3 N: 4.700.000 300.000/mm3

Theo kt qu bc u nghin cu mt s ch tiu sinh hc ca ngi Vit Nam nm 1996, s lng hng cu trong mu ca ngi Vit Nam bnh thng c khc nhau tu theo tc gi. (bng 1). Bng 1: S lng hng cu trong mu ngoi vi ca ngi Vit Nam Tc gi Trung Phn (min Bc) Nam (/mm ) N (/mm )
3 3

Nguyn Ngc Minh (min Trung) 4.510.000 410.000 4.320.000 210.000

Trn Vn B (min Nam) 4.920.000 680.000 4.520.000 540.000

5.110.000 300.000 4.600.000 250.000

S lng hng cu c th thay i trong mt s trng hp sinh l. tr s sinh, s lng hng cu cao trong vng mt hai tun u, sau c hin tng v hng cu gy vng da sinh l. Ngoi ra, s lng hng cu c th tng nhng ngi lao ng nng, sng vng cao.

Hnh 1: Qu trnh bit ho cc dng t bo mu 3. Chc nng Chc nng ch yu ca hng cu l vn chuyn oxy ti cc t chc. Ngoi ra hng cu cn c cc chc nng sau: vn chuyn mt phn CO2 (nh hemoglobin), gip huyt tng vn chuyn CO2(nh enzym carbonic anhydrase), iu ho cn bng toan kim nh tc dng m ca hemoglobin. 3.1. Cu trc ca hemoglobin

Hemoglobin cn gi huyt sc t, l chromoprotein gm hai thnh phn l nhn heme v globin. (hnh 2) Heme l mt sc t . Mi heme gm mt vng porphyrin v mt Fe2+ chnh gia. Mt phn t hemoglobin c bn nhn heme, chim 5%. Globin l mt protein gm bn chui polypeptid ging nhau tng i mt. Hemoglobin ngi bnh thng l HbA gm hai chui a v hai chui b. Hemoglobin thi k bo thai l HbF gm hai chuia v hai chui g.

Hnh 2: Cu to phn t hemoglobin S bt thng ca cc chui globin s lm thay i c im sinh l ca phn t Hb. V d, trong bnh thiu mu hng cu hnh lim, acid amin valin thay th cho glutamic ti mt v tr trong mi chui b lm HbA tr thnh HbS. Nng hemoglobin ca ngi bnh thng l: Nam: N: Tr em: 13,5-18 g/100 ml (g%) 12-16 g/100 ml (g%) 14-20 g/100 ml (g%)

Nng hemoglobin ca ngi Vit Nam bnh thng c nghin cu nm 1996 c tr s khc nhau tu theo tng tc gi. (bng 2) Bng 2: Nng hemoglobin ca ngi Vit Nam bnh thng. Tc gi Trung Phn (min Bc) Nam N 3.2. Chc nng vn chuyn kh 3.2.1. Vn chuyn kh O2 Hng cu vn chuyn O2 t phi n t chc nh phn ng sau: Hb + O2 HbO2 (oxyhemoglobin) Trong O2 c gn lng lo vi Fe2+. y l phn ng thun nghch, chiu phn ng do phn p O2 quyt nh. Trong phn t Hb, O2 khng b ion ho m n c vn chuyn di dng phn t O2. 157 7 g/l 135 7 g/l Nguyn Ngc Minh (min Trung) 133,9 9,8 g/l 130 5,7 g/l Trn Vn B (min Nam) 142,8 10,8 g/l 128,5 10,8 g/l

Khi ht phi khng kh nhiu CO (carbon monoxide), hemoglobin s kt hp CO to ra carboxyhemoglobin theo phn ng: Hb + CO HbCO i lc ca Hb i vi CO gp hn 200 ln i vi O2, v vy mt khi kt hp vi CO th Hb khng cn kh nng vn chuyn O2 na. Du hiu u tin l da sng, bnh nhn ri vo trng thi kch thch, ri bun ng, hn m v t vong. Kh CO thng c sinh ra khi t chy nhin liu khng hon ton. iu tr bng cch a bnh nhn ra khi mi trng nhiu CO, ng thi cho th O2. Lng CO trong khng kh l ch s o mc nhim mi trng. Khi mu tip xc vi nhng thuc hoc ho cht c tnh oxy ho, Fe2+ trong nhn heme chuyn thnh 3+ Fe v hemoglobin tr thnh methemoglobin khng cn kh nng vn chuyn O2. Methemoglobin khi hin din trong mu nhiu s gy triu chng xanh tm. Tnh trng ny xy ra khi ng c mt s dn cht ca anilin, sulfonamide, phenacetin, nitroglycerin, nitrate trong thc phm ... 3.2.2. Vn chuyn kh CO2 Hng cu vn chuyn CO2 t t chc v phi theo phn ng sau: Hb + CO2 HbCO2 (carbaminohemoglobin) CO2 c gn vi nhm NH2 ca globin. y cng l phn ng thun nghch, chiu phn ng do phn p CO2 quyt nh. Ch khong 20% CO2 c vn chuyn di hnh thc ny, cn li l do mui kim ca huyt tng vn chuyn. 4. S sinh sn hng cu 4.1. Qu trnh bit ho dng hng cu

S 1: Qu trnh bit ho dng hng cu Tin nguyn hng cu l t bo u tin ca dng hng cu m chng ta nhn dng c. Qu trnh bit ho t tin nguyn hng cu din ra theo s 1. Cc giai on t t bo gc n hng cu li din ra trong tu xng, sau hng cu li c phng thch ra mu ngoi vi 24-48 gi th mng li bin mt v tr thnh hng cu trng thnh. T l hng cu li trong mu ngoi vi khng qu 1%. T l ny cho php nh gi tc sinh hng cu ca tu xng sau liu trnh iu tr thiu mu hoc sau khi b mt mu cp. S tng hp hemoglobin xy ra t giai on tin nguyn hng cu v ngy cng tng dn. n giai on nguyn hng cu a acid th t mc bo ho.

4.2. S iu ho sinh sn hng cu S lng hng cu trong h thng tun hon c iu ho cht ch n ch thay i trong mt phm vi hp. S lng hng cu phi m bo hai yu cu sau: cung cp oxy cho t chc. Khng qu nhiu trnh cn tr s lu thng mu. Nng oxy t chc l yu t chnh kim sot tc sinh hng cu. Tc sinh hng cu s tng trong nhng trng hp lng oxy vn chuyn n t chc khng p ng nhu cu ca t chc v ngc li. Tc sinh hng cu s tng trong cc trng hp sau: Khi thiu mu do mt mu, tu xng s tng sinh sn hng cu. Ngoi ra, nhng ngi b thng tn tu xng mt phn do liu php tia X chng hn, phn tu xng cn li s tng sinh sn hng cu p ng nhu cu c th. Nhng ngi sng vng cao. Cc trng hp suy tim ko di hoc nhng bnh phi mn tnh. Yu t kch thch sinh sn hng cu l ni tit t erythropoietin. ngi bnh thng, 90% erythropoietin do thn tit ra, phn cn li ch yu do gan sn xut. Khi thiu oxy t chc, erythropoietin s c tng tit trong mu v chnh n thc y qu trnh to tin nguyn hng cu t t bo gc to mu trong tu xng. Khi tin nguyn hng cu c hnh thnh th erythropoietin li thc y n nhanh chng chuyn qua cc giai on nguyn hng cu hnh thnh hng cu trng thnh. Ngoi ra erythropoietin cn tng tng hp Hb trong nguyn hng cu v tng vn chuyn hng cu li ra mu ngoi vi. 4.3. Cc thnh phn dinh dng tham gia to hng cu to hng cu, cn phi cung cp y protein, st, v cc vitamin B12, B9 (acid folic). Protein cn cho s tng hp cc chui globin v cc thnh phn cu trc ca hng cu. St cn to nhn heme: nhu cu st hng ngy l 1 mg nam gii v 2 mg n. i vi ph n c thai nhu cu st cng tng cao nn phi cung cp thm vin st mi ngy. Vitamin B12 v acid folic cn cho qu trnh tng hp DNA phc v s phn chia t bo. Nhu cu B12 mi ngy l 1-3 mg. 5. i sng hng cu i sng trung bnh ca hng cu trong mu ngoi vi l 120 ngy. Theo thi gian, mng hng cu s mt dn tnh mm do v cui cng hng cu s v khi i qua cc mao mch nh ca lch. Hemoglobin phng thch ra t hng cu v s b thc bo bi cc i thc bo c nh ca gan, lch v tu xng. i thc bo s gii phng st vo mu; st ny cng vi st t thc n do rut non hp thu, c vn chuyn di dng transferrin dn tu xng to hng cu mi, hoc n gan v cc m khc d tr di dng ferritin v hemosiderin. Phn porphyrin ca heme s c chuyn ho qua nhiu giai on trong i thc bo to thnh sc t bilirubin, cht ny c gii phng vo mu, n gan ri bi tit vo mt. S chuyn ho ca bilirubin s c nghin cu k trong chng tiu ho. Ngoi ra phn globin ca hemoglobin c ging ho thnh cc acid amin m s c s dng tng hp cc protein cho c th. 6. Mt s ri lon lm sng ca dng hng cu 6.1. Thiu mu Theo T chc Y t th gii, thiu mu l gim nng hemoglobin: Nam: < 13 g/100 ml mu

N: Tr s sinh:

< 12 g/100 ml mu < 14 g/100 ml mu

Thiu mu c th do giun mc, xut huyt, huyt tn, suy tu ... 6.2. Bnh a hng cu Cn gi l bnh Vaquez, gy ra do s khim khuyt gen xy ra trong dng nguyn bo to mu. Nhng nguyn bo ny khng ngng to hng cu d s lng qu . S lng hng cu thng l 7-8 triu/mm3. IV. Bch cu Bch cu l nhng t bo mu c tc dng bo v c th chng li cc tc nhn gy bnh. 1. Cc loi bch cu Da vo hnh dng, cu trc v cch bt mu phm nhum, ngi ta chia bch cu ra lm hai nhm chnh l bch cu ht v bch cu khng ht. 1.1. Bch cu ht Cha nhng ht trong bo tng m c th thy di knh hin vi quang hc. Tu theo cch bt mu phm nhum ca cc ht m chng c tn l bch cu ht trung tnh, a acid, a kim. Ngoi ra, do nhn ca cc bch cu ht ny c nhiu thu nn chng cn c tn l bch cu a nhn. 1.2. Bch cu khng ht Trong bo tng khng c cc ht m c th thy c di knh hin vi quang hc do kch thc chng nh v bt mu phm nhum km. C hai loi bch cu khng ht l bch cu lympho v bch cu mono. Nhn ca cc bch cu khng ht ny khng chia thu nn chng cn c tn l bch cu n nhn. 2. S sinh sn v i sng bch cu 2.1. Bch cu ht v bch cu mono Ton b qu trnh sinh sn v bit ho to nn cc loi bch cu ht v bch cu mono din ra trong tu xng. Chng c d tr sn tu xng, khi no c th cn n, chng s c a vo mu lu thng. Bch cu ht sau khi ri tu xng th lu hnh trong mu khong 4-8 gi ri xuyn mch vo t chc, tn ti thm khong 4-5 ngy. Khi bch cu thc hin chc nng bo v c th ca minh, chng hn chng nhim trng, th n s cht sm hn. Bch cu mono cng c thi gian lu hnh trong mu ngn, khong 10-20 gi. Sau s xuyn mch vo t chc. Ti t chc chng s tng kch thc v tr thnh i thc bo t chc. dng ny chng c th sng hng thng, thm ch hng nm. 2.2. Bch cu lympho Cc t bo lympho u c chung ngun gc t trong bo thai l t bo gc to mu a nng. Cc t bo ny s bit ho thnh t bo gc bit ho ca dng lympho to ra t bo lympho. Trc khi tr thnh cc t bo lympho trng thnh khu tr cc t chc bch huyt, chng c x l ti nhng ni khc nhau trong c th. Mt s di tr n tuyn c c x l v c gi l lympho T. Mt s khc c x l gan trong nhng thng gia ca thai k, tu xng trong nhng thng sau ca thai k v sau khi sinh, chng c gi l lympho B. T cc t chc bch huyt, bch cu lympho vo h tun hon lin tc theo dng bch huyt. Sau vi gi, chng xuyn mch vo t chc ri vo dng bch huyt tr v t chc bch huyt hoc vo mu ln na ri ln na ... Cc

bch cu lympho c thi gian sng hng tun, hng thng hoc thm ch hng nm tu thuc nhu cu ca c th. 3. Chc nng ca bch cu Chc nng chung ca bch cu l chng li cc tc nhn l xm nhp vo c th. Nhn chung, chng c cc c tnh sau thch hp vi chc nng ny: Xuyn mch: t bin i hnh dng chui qua gia cc t bo ni m mch mu vo t chc xung quanh. Vn ng: theo kiu a-mp (bng chn gi) n cc t chc cn n.

- Ho ng ng: bch cu b hp dn n v tr tn thng khi c cc ho cht c gii phng ra bi t bo tn thng hoc vi khun, v khi c cc phc hp min dch. Thc bo: bt cc vt l a vo trong bo tng ri tiu ho chng.

Tuy nhin khng phi loi bch cu no cng c y cc c tnh trn.

Hnh 3: Cc t bo thc bo di chuyn t mu n t chc tn thng 3.1. Chc nng ca bch cu ht trung tnh Bch cu ht trung tnh l hng ro ca c th c kh nng chng li vi khun sinh m. Chng rt vn ng v thc bo tch cc. Bch cu trung tnh c th tiu ho, hu hoi nhiu loi vi khun, nhng thnh phn nh, v fibrin. Hu ht cc ht bo tng ca chng l cc tiu th cha enzym thu phn. Cc ht khc cha cc protein khng khun. Ngoi ra, bch cu ht trung tnh cn cha cc cht oxy ho mnh c tc dng tiu dit vi khun. Bch cu ht trung tnh l bch cu u tin n v tr vi khun xm nhp vi s lng ln. Trong qu trnh thc bo vi khun, nhiu bch cu trung tnh b cht v to thnh m ti v tr tn thng. Mi bch cu ny thc bo ti a khong 5-20 vi khun. 3.2. Chc nng ca bch cu ht a kim Bch cu ht a kim rt ging mt loi t bo khc trong t chc bn ngoi mao mch gi l dng bo (mast cell).

Bch cu ht a kim v dng bo c th phng thch heparin ngn cn qu trnh ng mu v thc y s vn chuyn m t mu sau ba n nhiu cht bo. Cc t bo ny ng vai tr quan trng trong phn ng d ng. Do cc khng th gy phn ng d ng (loi IgE) c khuynh hng n gn trn b mt dng bo v bch cu a kim. Khi c s kt hp gia khng th ny vi d ng nguyn, dng bo v bch cu a kim s v ra v gii phng histamine, cng nh bradykinin, serotonin, cht phn ng chm ca sc phn v (slow-reacting substance of anaphylaxis), enzym tiu protein....to nn bnh cnh in hnh ca d ng. 3.3. Chc nng bch cu ht a acid Bch cu ht a acid t vn ng hn bch cu trung tnh v thc bo cng t tch cc hn, chng khng thc bo vi khun. Chc nng u tin ca bch cu ht a acid l kh c protein l nh cc enzym c bit trong ht bo tng. Bch cu a acid thng tp trung nhiu nim mc ng h hp, tiu ho, tit niu-sinh dc ngn chn cc tc nhn l xm nhp c th. Chng c th tit ra cc cht c i vi k sinh trng. c bit l cc loi sn mng (schistosomum) hoc giun xon (trichinella). Bch cu ht a acid cn tp trung ni c phn ng d ng xy ra, chng tit ra cc enzym chng li tc dng ca histamine v cc cht trung gian khc trong phn ng d ng. Ngoi ra, chng cn c kh nng thc bo cc phc hp khng nguyn-khng th. V vy, chng ngn cn khng cho tin trnh vim lan rng. 3.4. Chc nng bch cu mono - i thc bo Cc bch cu mono cha thc s trng thnh, kh nng tiu dit tc nhn nhim khun ca chng cn km. Nhng khi vo trong t chc, tr thnh i thc bo vi kch thc ln hn v nhiu tiu th trong bo tng, chng c kh nng chng tc nhn gy bnh rt mnh lit. Kh nng thc bo ca chng mnh hn bch cu ht trung tnh nhiu, chng c th thc bo khong 100 vi khun. i thc bo cn c th thc bo cc thnh phn ln hn nh hng cu cht, k sinh trng st rt. Ngoi ra, chng cn c lipase gip tiu ho cc vi khun c v bc lipid dy. Sau khi thc bo, chng c th y cc sn phm ra v thng sng st vi thng. Cc i thc bo cn c chc nng trnh din khng nguyn cho cc t bo c thm quyn min dch. 3.5. Chc nng bch cu lympho C 3 loi t bo lympho l: 3.5.1. T bo dit t nhin (NK: natural killer) Cc t bo NK hin din lch, hch, tu xng v mu. Chng thng tn cng cc vi sinh vt gy bnh v mt s t bo khi u tin pht. C ch tc dng ca chng cha c r rng. 3.5.2. Lympho B Bch cu lympho B bo v c th bng p ng min dch dch th (qua trung gian khng th). N chng li cc loi vi khun v mt s virus. Khi c cc vi khun xut hin, lympho B nhn din khng nguyn tng ng v c hot ho. Khi n c kh nng phn bo v bit ho thnh tng bo (plasma cell). Cc tng bo ny s sn xut khng th chng li vi khun xm nhp. Khng th tiu dit cc vi khun hoc bt hot c t ca chng. Mt s lympho B c sinh ra trn khng tr thnh tng bo m tr thnh lympho B nh sn sng p ng nhanh v mnh khi c cng loi vi khun xm nhp ln sau. 3.5.3. Lympho T

Bch cu lympho T l t bo tham gia p ng min dch qua trung gian t bo. Lympho T c kh nng chng li cc tc nhn nh virus, nm, t bo mnh ghp, t bo ung th v vi loi vi khun. Khi c cc tc nhn xut hin trong c th, cc lympho T s nhn din khng nguyn c hiu vi n v c hot ho. Sau chng tr nn ln hn, sinh sn to nn hng ngn lympho T c th nhn din khng nguyn xm nhp ny. C 3 loi lympho T chnh: T gip (Th: helper): kch thch s pht trin v sinh sn ca cc lympho T c, T c ch. Th cn kch thch s pht trin v bit ho lympho B thnh tng bo. Ngoi ra, Th cn tit cc cht lm tng cng hot ng bch cu trung tnh v i thc bo. T c (Tc: cytotoxic): tiu dit trc tip cc t bo b nhim tng ng. Tc cng tit cc cht khuch i kh nng thc bo ca i thc bo. T c ch (Ts: suppressor): pht trin chm hn, n c tc dng c ch lympho Tc v Th lm cho p ng min dch khng pht trin qu mc. Mt s lympho T tr thnh t bo T nh c kh nng khi pht mt p ng min dch tng t khi c cng loi tc nhn gy bnh (khng nguyn) xm nhp nhng mc nhanh, mnh hn nhiu, gi l p ng min dch ln hai. Lu : Cc Th thuc loi lympho T4, cn Tc v Ts thuc loi lympho T8. T bo Th ng vai tr quan trng trong c qu trnh min dch trung gian t bo ln min dch dch th. Trong bnh AIDS cc HIV tn cng dng T4 (ch yu l Th) nn cc p ng min dch b t lit v c ch bo v khng c hiu cng b suy gim. Bnh nhn s cht do nhim trng c hi. p ng min dch ln sau nh vai tr ca T nh hoc B nh l c s min dch ca vic chng nga phng bnh. 4. S lng bch cu - Cng thc bch cu 4.1. S lng bch cu Bnh thng s lng bch cu trong mu trung bnh khong 7000/mm3. Tng trong cc bnh nhim khun cp, vim hoc Leukemia Gim trong cc trng hp suy tu. 4.2. Cng thc bch cu Cng thc bch cu l t l phn trm ca cc loi bch cu. C nhiu loi cng thc bch cu nhng trn lm sng thng s dng cng thc bch cu thng thng. Ngi bnh thng c th c cng thc bch cu nh sau: Bch cu a nhn trung tnh: 60-70 % Bch cu a nhn a acid: 2-4 % Bch cu a nhn a kim: 0,5-1 % Bch cu mono: 3-8 % Bch cu lympho: 20-25 % S thay i t l cc loi bch cu gip cc nh lm sng chn on nguyn nhn. 4.2.1. Bch cu trung tnh Tng khi nhim khun cp, bng, stress, vim. Gim khi nhim tia x, s dng mt vi loi thuc (nh thuc khng gip), bnh Lupus ban . 4.2.2. Bch cu a acid Tng khi c phn ng d ng, nhim k sinh trng, bnh t min, suy thng thn. Gim khi s dng mt s thuc (corticoid), hi chng Cushing, stress. 4.2.3. Bch cu a kim Tng trong mt s trng hp d ng, bnh bch cu, suy gip.

Gim trong trng hp mang thai, rng trng, stress, cng gip (v bch cu ny chim t l thp nn rt kh pht hin gim). 4.2.4. Bch cu lympho Tng trong nhim virus, bnh min dch, bnh bch cu. Gim khi b bnh nng ko di, tng nng steroid, b c ch min dch. 4.2.5. Bch cu mono Tng khi b nhim virus, nm, lao, mt s bnh bch cu v bnh mn tnh. Gim bch cu m-n rt him xy ra. 5. Mt s ri lon lm sng dng bch cu 5.1. Gim bch cu Gim bch cu thng xy ra khi tu xng ngng sn xut bch cu, lm vi khun v tc nhn gy bnh khc c iu kin thun li xm nhp vo c th. Bnh nhn c th cht trong vng 1 tun do nhim khun nng. Nguyn nhn thng do b nhim tia gam-ma (phng x nguyn t), ho cht c nhn benzene, anthracene. Ngoi ra c th do mt s thuc nh chloramphenicol, thiouracil, barbiturate. 5.2. Bnh bch cu (Leukemia, ung th mu) l s sinh sn bch cu khng th kim sot gy nn do t bin ung th ca cc t bo dng tu hoc dng lympho. Bnh bch cu c c trng bi s gia tng qu mc s lng bch cu bt thng trong mu. Bnh nhn thng b nhim trng, thiu mu nng, d xut huyt Bnh nhn bnh bch cu cp c th cht sau t thng khng iu tr, cn bnh bch cu mn c th sng 10-20 nm. V. Nhm mu Trn mng hng cu ngi, ngi ta tm ra khong 30 khng nguyn thng gp v hng trm khng nguyn him gp khc. Hu ht nhng khng nguyn l yu, ch c dng nghin cu di truyn gen v quan h huyt thng. Tuy nhin c hai nhm khng nguyn c bit quan trng c th gy phn ng trong truyn mu l h thng khng nguyn ABO v Rh. 1. H thng nhm mu ABO 1.1. Phn loi Trong h thng ny c 2 loi khng nguyn l A v B nm trn mng hng cu. Ngoi ra trong huyt tng cn c 2 loi khng th l khng th khng A (khng th a) v khng th khng B (khng th b). Khng th a c kh nng ngng kt khng nguyn A, khng th b c kh nng ngng kt khng nguyn B. Ngi ta da vo s hin din khng nguyn A, B trn mng hng cu phn loi h thng nhm mu ABO (bng 3). Bng 3: H thng nhm mu ABO Tn nhm mu T l % Da trng A 41 Vit Nam 21,5 KN trn mng hng cu A KT trong huyt tng

B AB O

9 3 47

29,5 6 43

B A v B Khng c A, B

a Khng c a v b a v b

S xut hin khng nguyn A, hoc khng nguyn B trn mng hng cu c quy nh bi gien (gene). Khng th a v b c to ra bi cc t bo sn xut khng th. Sau khi sinh, khng th cha xut hin trong huyt tng. Hai n tm thng sau c th a tr mi bt u sn xut khng th (ngi nhm mu A th sn xut khng th b, tng t cho cc nhm mu khc). Nng khng th t ti a vo nhng nm 8-10 tui, sau n s gim dn. 1.2. Phn ng truyn mu Khi truyn nhm nhm mu, phn ng truyn mu c th xy ra, trong hng cu ca mu ngi cho b ngng kt, rt him khi mu truyn vo gy ngng kt hng cu ngi nhn. Cc hng cu ngng kt thnh tng m m c th bt kn cc mch mu nh. Vi gi hoc vi ngy tip theo, s xy ra tan mu (v hng cu). i khi ngay sau khi truyn nhm nhm mu, hin tng tan mu xy ra lp tc. Mt trong nhng hu qu gy t vong ca phn ng truyn mu l suy thn cp. 1.3. ng dng trong truyn mu 1.3.1. Nguyn tc truyn mu Nguyn tc chung: Khng c khng nguyn v khng th tng ng gp nhau. Nh vy chng ta ch c php truyn mu cng nhm. Nguyn tc ti thiu: Khi truyn mt lng mu nh (<200 ml), khng c khng nguyn trn mng hng cu ca ngi cho gp khng th tng ng trong huyt tng ngi nhn. C th truyn mu theo s truyn mu kinh in (hnh 4). Khi truyn mu khc nhm (theo ng s truyn mu) phi tun th cc quy tc sau: + Ch truyn mt ln + Lng mu truyn khng qu 200 ml + Tc truyn chm 1.3.2. Th phn ng cho Trc khi truyn mu cn th phn ng cho d l truyn cng nhm. Hng cu ca ngi cho c trn vi huyt tng ngi nhn trn mt phin knh. Nu khng xy ra ngng kt, chng t ngi nhn khng c khng th tn cng hng cu ngi cho. Cng nn kim tra phn ng gia huyt tng ngui cho v hng cu ngi nhn, d rng n rt him khi gy phn ng truyn mu.

Hnh 4: S truyn mu kinh in 2. H thng nhm mu Rhesus (Rh) 2.1. Phn loi C 6 loi khng nguyn Rh, chng c k hiu l C, D, E, c, d, e. Mt ngi c khng nguyn C th khng c c v ngc li, iu ny cng ng i vi cc cp D-d v E-e. Do phng thc di truyn ca cc yu t ny, mi ngi chng ta c 3 khng nguyn thuc 3 cp C-c, D-d, E-e (chng hn CDE; CdE; cdE; cDe...). Khng nguyn D l thng gp nht v c tnh khng nguyn mnh nht nn nhng ngi mang khng nguyn D c gi Rh dng, nhng ngi khng mang khng nguyn D c gi l Rh m. Mt iu cn lu l trong h thng nhm mu Rh, khng th khng Rh khng c sn t nhin trong mu. Khng th ch sinh ra trong mu ngi Rh m khi ngi ny c truyn mu Rh dng hoc trng hp m Rh m mang bo thai Rh dng. l kt qu ca qu trnh p ng min dch. Bng 4: H thng nhm mu Rhesus Tn nhm mu Khng nguyn D Khng th t nhin Rh
+

T l % u M 85 15 Kinh (VN) 99,92 0,08 Mng 100 0

C Rh Khng

Khng Khng

2.2. Tai bin do bt ng nhm mu h Rh 2.2.1. Trong truyn mu Ngi nhm mu Rh m c truyn mu Rh dng, ln u tin hu nh khng xy ra tai bin. Tuy nhin, c th ngi ny bt u sn xut khng th khng Rh. Nng khng th t ti a sau 2-4 thng. Nu sau ngi ny li c truyn mu Rh dng th tai bin c th xy ra do khng th khng Rh c sn cng vi khng th khng Rh c to ra do p ng min dch ln hai s gy ngng kt hng cu Rh dng c truyn vo. Cn lu rng, c mt s ngi Rh m trong ln nhn mu Rh dng u tin sn xut khng th khng Rh vi s lng c ngha sau 2-4 tun. Nh vy, khng th c th gy ngng kt nhng hng cu Rh dng cn lu thng trong mu. Tuy nhin, phn ng xy ra mun ny rt nh nhng. 2.2.2. Trong sn khoa Xy ra i vi nhng ngi ph n Rh m ly chng Rh dng. Khi c thai, thai nhi c th l Rh dng hoc m. Trong ln mang thai Rh dng u tin, mt lng mu Rh dng ca thai nhi s vo tun hon m ch yu l lc sinh v kch thch c th ngi m sn xut khng th khng Rh. a tr sinh ra trong ln ny khng b nh hng g c. Tuy nhin, n ln mang thai tip theo, khng th khng Rh s vo tun hon thai nhi. Nu l thai Rh dng th khng th

khng Rh c th lm ngng kt hng cu thai nhi v gy cc tai bin sy thai, thai lu, hoc a tr sinh ra b hi chng vng da tan mu nng. Tht ra, trong thi gian mang thai yu t Rh ca bo thai phng thch vo trong dch bo thai v c th khuch tn vo mu m. Tuy nhin, trong ln mang thai u tin (ln u tin tip xc khng nguyn Rh) lng khng th to ra c th ngi m khng cao gy hi cho thai nhi.

Hnh 5: Tai bin sn khoa trong bt ng nhm mu Rhesus VI. Cm mu Cm mu l qu trnh ngn cn s chy mu. Khi mch mu b tn thng hoc t, qu trnh cm mu phi p ng nhanh chng, khu tr ti vng tn thng v c kim sot cht ch. Qu trnh cm mu c thc hin nh nhng c ch: co mch, hnh thnh nt tiu cu, ng mu, tan cc mu ng hoc pht trin m x trong cc mu ng ng kn vt thng. 1. Co mch Ngay khi mch mu b tn thng, thnh mch co li do cc c ch sau: Phn x thn kinh do au. S co mch ti ch, c khi pht trc tip bi thng tn thnh mch. Cc yu t th dch t t chc thng tn v tiu cu (thromboxane A2, serotonin v epinephrine). Thnh mch b thng tn cng nhiu th co mch cng mnh. S co mch ti ch c th ko di nhiu pht n vi gi. Trong thi gian ny c th din ra s hnh thnh nt tiu cu v ng mu. ngha: S co mch tc thi ny hn ch lng mu ra khi thnh mch tn thng. 2. S hnh thnh nt tiu cu 2.1. Sinh l tiu cu Tiu cu thc cht l mt mnh t bo c v ra t t bo nhn khng l. Sau khi c phng thch t tu xng, ch c 60-75% tiu cu lu thng trong mu, phn cn li c gi lch.

S lng bnh thng ca tiu cu trong mu l 150.000-300.000/mm3. i sng tiu cu thay i t vi ngy n hai tun. Tiu cu c kch thc 2-4 mm, khng c nhn nhng bo tng c nhiu ht. C 2 loi ht l: Ht alpha cha PDGF (platelet-derived growth factor) c tc dng gip lin vt thng. Ht m c cha ADP, ATP, Ca2+, serotonin v epinephrine. Ngoi ra tiu cu cn cha cc enzym tng hp thromboxane A2; yu t n nh fibrin, tiu th v cc kho d tr Ca2+. c bit, trong tiu cu c cc phn t actin, myosin, thrombosthenin gip n co rt. Mng ca tiu cu cha mt lng ln phospholipid. B mt ca tiu cu c mt lp glycoprotein ngn cn n dnh vo ni mc bnh thng. 2.2. S hnh thnh nt tiu cu Din ra theo cc pha nh sau: Kt dnh tiu cu: khi thnh mch b tn thng, lp collagen nm bn di t bo ni mc mch mu c l ra. Tiu cu s n dnh vo lp collagen ny. Tiu cu gii phng cc yu t hot ng: sau khi tiu cu kt dnh vi collagen, n tr nn c hot ho. Tiu cu phnh to ra, th cc chn gi v gii phng nhiu cht, trong c mt lng ln ADP, thromboxane A2. Kt tp tiu cu: ADP v thromboxane A2 hot ho cc tiu cu gn v lm chng dnh vo lp tiu cu ban u gi l kt tp tiu cu. Ri lp tiu cu n sau ny li gii phng cc cht hot ng lm hot ho v dnh thm lp tiu cu khc. C nh vy, cc lp tiu cu n dnh vo ch tn thng cng lc cng nhiu to nn nt tiu cu. Nu thng tn mch mu l nh th bn thn nt tiu cu c th lm ngng chy mu, nhng nu thng tn ln hn th phi nh thm s hnh thnh cc mu ng. ngha: S hnh thnh nt tiu cu c vai tr c bit quan trng trong vic bt kn cc thng tn nh cc mch mu nh xy ra hng trm ln mi ngy. 3. Qu trnh ng mu Bnh thng mu trong lng mch lun dng lng (sol). Tuy nhin, khi mch mu b tn thng hoc mu chy ra khi c th, mu s chuyn sang dng c (gel). Qu trnh hnh thnh dng gel c gi l qu trnh ng mu. Trong c th c hn 50 cht nh hng n s ng mu. Nhng cht thc y ng mu c gi l yu t ng mu, nhng cht ngn cn ng mu c gi l cht chng ng. Cc yu t ng mu kinh in c k hiu theo th t bng ch s La M nh sau: Yu t I : Fibrinogen Yu t II : Prothrombin Yu t III : Thromboplastin t chc Yu t IV : Calcium Yu t V : Proaccelerin Yu t VII : Proconvertin Yu t VIII : Yu t chng chy mu A Yu t IX : Yu t chng chy mu B cn gi l yu t Christmas Yu t X : Yu t Stuart Yu t XI : Tin Thromboplastin huyt tng Yu t XII : Yu t Hageman Yu t XIII : Yu t n nh Fibrin Qu trnh ng mu l mt chui cc phn ng xy ra theo kiu bc thang c chia thnh 3 giai on nh sau:

3.1. Giai on thnh lp phc hp prothrombinase Prothrombinase c hnh thnh bi 2 con ng: ngoi sinh v ni sinh. 3.1.1. Con ng ngoi sinh Con ng ny c khi pht bi yu t III (l thromboplastin t chc gmphospholipid v lipoprotein) c tit ra t b mt cc t bo t chc tn thng ngoi thnh mch. Yu t III vo mu hot ho yu t VII. Ri yu t VIIa (VII hot ho) cng thromboplastin t chc hot ho tip yu t X. Yu t Xa kt hp vi phospholipid (t t chc) v yu t V cng s c mt Ca2+ to nn phc hp prothrombinase.

S 2: S hnh thnh prothrombinase theo con ng ngoi sinh 3.1.2. Con ng ni sinh Con ng ny c khi pht khi bn thn mu b tn thng hoc mu tip xc vi lp collagen (c l ra do t bo ni mc tn thng). iu ny dn n s hot ho yu t XII v tiu cu (gii phng phospholipid tiu cu). Yu t XIIa s hot ho yu t XI, phn ng ny cn c kininogen v prekallikrein. Yu t XIa li hot ho yu t IX. Yu t VIIa trong con ng ngoi sinh cng tham gia hot ho yu t IX. Yu t IXa cng vi yu t VIIIa (yu t VIII c hot ho bi thrombin), phospholipid tiu cu s hot ho yu t X. Yu t Xa kt hp vi phospholipid (t tiu cu) v yu t V cng s c mt Ca2+ to nn phc hp prothrombinase. * Ngoi tr 2 bc u ca con ng ni sinh, tt c cc bc khc ca c hai con ng u cn Ca2+. 3.2. Giai on thnh lp thrombin Sau khi prothrombinase c hnh thnh, n chuyn prothrombin thnh thrombin ch sau vi giy. Trong phc hp prothrombonase, yu t Xa l mt enzym phn gii protein thc s, n chuyn prothrombin thnh thrombin. Mt khi thrombin c hnh thnh, n s hot ho yu t V. Ri yu t Va cng thc y tc dng ca yu t Xa to nn s iu ho ngc dng tnh (positive feedback). Thrombin cng l enzym phn gii protein, n cn c th tc ng ln chnh prothrombin tng to thrombin. Ngoi ra n cn thc y hot ho cc yu t VIII, IX, X, XI, XII, v s kt tp tiu cu. Nh vy, mt khi thrombin c hnh thnh, n s khi pht s iu ho ngc dng tnh lm nhiu thrombin c to ra hn na v qu trnh ng mu tip tc pht trin cho n khi c mt c ch ngn chn n li.

S 3: S hnh thnh prothrombinase theo con ng ni sinh 3.3. Giai on thnh lp fibrin v cc mu ng Thrombin cng vi Ca2+ chuyn fibrinogen thnh phn t fibrin n phn. Cc fibrin n phn ny ni vi nhau to thnh cc si fibrin t hnh thnh mng li ca cc mu ng. Lc u cc cu ni gia cc fibrin l cu ni hydro lng lo nn cc mu ng yu, d tan r. Sau vi pht, nh s c mt ca yu t n nh fibrin (yu t XIII, c hot ho bi thrombin) cc cu ni ng ho tr thay th cu ni hydro, ng thi c thm cc dy ni cho gia cc si fibrin k cn to nn mng li fibrin bn vng. Mng li ny giam gi cc t bo mu, tiu cu, huyt tng to nn cc mu ng. ngha: Cc mu ng bt thnh mch tn thng ngn cn mt mu. Trong qu trnh ng mu, con ng ngoi sinh v ni sinh c khi pht ng thi. Tuy nhin, con ng ngoi sinh din ra nhanh hn. N ch cn 15 giy, trong khi con ng ni sinh phi cn 1-6 pht gy ng mu. Sau khi c hnh thnh 20-60 pht, cc mu ng co li v tit ra mt cht dch gi l huyt thanh. Nh vy, huyt thanh khc huyt tng ch l mt i cc yu t ng mu. Tiu cu b giam gi trong cc mu ng ng vai tr quan trng trong vic co cc mu ny, nh vo cc protein co nh thrombosthenin, actin v myosin. Tiu cu dnh vi cc si fibrin nn khi co li chng lm cc si ny cng ni cht vi nhau. Cc tiu cu ny cn tip tc tit yu t n nh fibrin lm tng cng cc cu ni gia cc si fibrin k cn. Ngoi ra, s co ny cn c thc y bi thrombin v bi Ca2+ c tit ra t cc kho d tr trong tiu cu. Cui cng, cc mu ng tr thnh mt khi nh hn v c hn. ngha: S co cc mu ng ko cc b ca thng tn mch mu st vo nhau nn cng lm vt thng c bt kn hn v n nh c s chy mu. 4. Tan cc mu ng - S hnh thnh m x Mt khi cc mu ng c hnh thnh, n din tin theo 2 cch sau:

Cc cc mu ng hnh thnh ti vt thng nh ca thnh mch s b xm ln bi cc nguyn bo x, ri hnh thnh nn t chc lin kt gip lin so vt thng. Cc cc mu ng ln hn hoc cc mu ng trong lng mch s b tan ra di tc dng ca h thng tan mu. Hin tng tan cc mu ng din ra nh sau: khi cc mu ng c hnh thnh, plasminogen cng b giam gi bn trong n. Di tc dng ca yu t hot ho plasminogen t chc (t-PA), plasminogen s chuyn thnh plasmin c tc dng tiu protein. Plasmin s tiu hu cc si fibrin cng nh mt s yu t ng mu v lm cc mu ng tan ra. tPA c t chc tn thng hoc t bo ni mc tit ra khong 1 ngy (hoc mun hn) sau khi cc mu ng c hnh thnh. Ngoi ra, thrombin v yu t XIIa cng ng vai tr quan trng trong vic hot ho plasminogen thnh plasmin. ngha: S tan cc mu ng gip dn sch cc cc mu ng trong t chc v ti thng mch mu, to iu kin lin so. c bit n gip ly i cc huyt khi nh trong mch mu nh trnh thuyn tc mch. 5. Mt s ri lon cm mu 5.1. Thiu vitamin K Vitamin K rt cn cho s tng hp cc yu t ng mu II, VII, IX, X ti gan. V vy khi thiu ht vitamin K s gy xut huyt. 5.2. Bnh Hemophilia (bnh a chy mu) Do thiu cc yu t ng mu VIII (Hemophilia A); IX (Hemophilia B). y l bnh di truyn qua nhim sc th X. Bnh nhn b xut huyt sau chn thng, c khi l chn thng rt nh khng nhn bit c. 5.3. Gim tiu cu Thng gp l bnh gim tiu cu nguyn pht (v cn). Xut hin nhiu nt xut huyt trn ton c th. 5.4. Huyt khi Gy thuyn tc mch. Thng gp trong x va mch mu, nhim trng, chn thng, hoc mu chy chm. 5.5. ng mu ri rc trong lng mch Do s hin din ca cc m cht hoc tn thng trong c th; hoc c th gp trong sc nhim khun (do vi khun hoc ni c t ca n). c trng ca bnh l triu chng chy mu do cc yu t ng mu b s dng trong qu trnh ng mu, khng cn duy tr cm mu.