Нутритивный статус у больных с хронической почечной
advertisement
Îáçîðû è ëåêöèè Íóòðèòèâíûé ñòàòóñ ó áîëüíûõ ñ õðîíè÷åñêîé ïî÷å÷íîé íåäîñòàòî÷íîñòüþ (Îáçîð ëèòåðàòóðû) Å.Â. Øóòîâ Êàôåäðà íåôðîëîãèè è ãåìîäèàëèçà ÃÎÓ ÄÏÎ ÐÌÀÏÎ Ðîñçäðàâà, ã. Ìîñêâà Nutr itional status in patients with chronic renal failure 4ALEAM E.V. Shutov Êëþ÷åâûå ñëîâà: õðîíè÷åñêàÿ ïî÷å÷íàÿ íåäîñòàòî÷íîñòü, íóòðèòèâíûé ñòàòóñ, áåëêîâîýíåðãåòè÷åñêàÿ íåäîñòàòî÷íîñòü, èíäåêñ ìàññû òåëà. Çíà÷åíèå íóòðèòèâíîãî ñòàòóñà Êîëè÷åñòâî áîëüíûõ ñ òåðìèíàëüíîé ñòàäèåé õðîíè÷åñêîé ïî÷å÷íîé íåäîñòàòî÷íîñòè (ÒÕÏÍ) â ìèðå ïðîãðåññèâíî óâåëè÷èâàåòñÿ. Òàê, çà ïîñëåäíèå 5 ëåò ÷èñëî áîëüíûõ, íàõîäÿùèõñÿ íà çàìåñòèòåëüíîé ïî÷å÷íîé òåðàïèè (ÇÏÒ), óâåëè÷èëîñü áîëåå ÷åì íà 25% è íà äàííûé ìîìåíò íàñ÷èòûâàåò áîëåå 2 ìèëëèîíîâ ÷åëîâåê. Ïðè ýòîì íàèáîëüøåå êîëè÷åñòâî áîëüíûõ, ïîëó÷àþùèõ ÇÏÒ, îòìå÷åíî â ßïîíèè 2230 ïàöèåíòîâ íà 1 ìëí æèòåëåé è â ÑØÀ: 1650 áîëüíûõ íà 1 ìëí æèòåëåé.  òî æå âðåìÿ íàèáîëüøèé ðîñò ÷èñëà ïàöèåíòîâ, íàõîäÿùèõñÿ íà ÇÏÒ, çàôèêñèðîâàí â ðàçâèâàþùèõñÿ ñòðàíàõ (â òîì ÷èñëå â Ðîññèè) ñâûøå 50% çà 5 ëåò. Îäíîé èç âàæíåéøèõ ïðîáëåì ó ýòîé êàòåãîðèè áîëüíûõ ÿâëÿåòñÿ íåäîñòàòî÷íîñòü ïèòàíèÿ, êîòîðàÿ â çíà÷èòåëüíîé ñòåïåíè îïðåäåëÿåò èõ çàáîëåâàåìîñòü è ëåòàëüíîñòü [45]. Íåîáõîäèìî îòìåòèòü, ÷òî íàðóøåíèÿ íóòðèöèîííîãî ñòàòóñà âñòðå÷àþòñÿ ó 20 50% áîëüíûõ â äîäèàëèçíîé ñòàäèè ÕÏÍ [13, 80] è åùå ÷àùå ó áîëüíûõ íà äèàëèçå 1070% [84].  îòëè÷èå îò îáùåé ïîïóëÿöèè ó áîëüíûõ íà ÇÏÒ îòìå÷àåòñÿ áîëåå íèçêàÿ ëåòàëüíîñòü ñðåäè ïàöèåíòîâ ñ áîëüøåé ìàññîé òåëà [42]. Âïåðâûå ýòîò ôàêò áûë çàôèêñèðîâàí âî ôðàíöóçñêîì èññëåäîâàíèè â 1982 ã. [18].  ïîñëåäóþùåì S.F. Leavey è ñîàâò. [49] áûëî ïîêàçàíî, ÷òî áîëåå âûñîêàÿ âûæèâàåìîñòü ó äèàëèçíûõ áîëüíûõ îòìå÷àëàñü ïðè ïîâûøåííîì èíäåêñå ìàññû òåëà (ÈÌÒ) (>27,5), ó áîëüíûõ ñ íîðìàëüíûì è ñíèæåííûì ÈÌÒ âûæèâàåìîñòü áûëà íèæå (íîðìàëüíûå ïîêàçàòåëè èíäåêñà êîëåáëþòñÿ îò 20 äî 25, èõ ñíèæåíèå íèæå 18 ðàññìàòðèâàåòñÿ êàê ïîêàçàòåëü íåäîñòàòî÷íîãî ïèòàíèÿ, ïîâûøåíèå âûøå 27 êàê îæèðåíèå). Íà 1346 ïàöèåíòàõ, íàõîäÿùèõñÿ íà ãåìîäèàëèçå (ÃÄ), E. Fleischmann è ñîàâò. [25] áûëî ïðîäåìîíñòðèðîâàíî, ÷òî óâåëè÷åíèå ÈÌÒ íà îäíó åäèíèöó ñîïðîâîæäàåòñÿ ñíèæåíèåì ëåòàëüíîñòè íà 10%. Îäíîé èç ãëàâíûõ ïðè÷èí ñìåðòíîñòè ó ïàöèåíòîâ ñ ÒÕÏÍ, êàê è â îáùåé ïîïóëÿöèè, ÿâëÿþòñÿ ñåðäå÷íîñîñóäèñòûå çàáîëåâàíèÿ (ÑÑÇ) [25]. Îäíàêî ïðè èññëå- äîâàíèè ôàêòîðîâ ðèñêà ðàçâèòèÿ ÑÑÇ îêàçàëîñü, ÷òî â îòëè÷èå îò îáùåé ïîïóëÿöèè îæèðåíèå, ïîâûøåííîå àðòåðèàëüíîå äàâëåíèå (ÀÄ), ãèïåðõîëåñòåðèíåìèÿ, ãèïåðãîìîöèñòåèíåìèÿ àññîöèèðóþòñÿ ñ ëó÷øåé âûæèâàåìîñòüþ ó ïàöèåíòîâ íà ãåìîäèàëèçå [40, 41, 61, 62, 74]. Ëó÷øàÿ âûæèâàåìîñòü ñðåäè ëèö ñ âûñîêèì ÈÌÒ íàáëþäàåòñÿ è ó áîëüíûõ íà ïåðèòîíåàëüíîì äèàëèçå (ÏÄ) [77]. Ýòîò ôåíîìåí áûë íàçâàí îáðàòíîé ýïèäåìèîëîãèåé [41]. Íàäî çàìåòèòü, ÷òî ýòî íå åäèíñòâåííîå èñêëþ÷åíèå, êîãäà âûæèâàåìîñòü âûøå ïðè áîëüøåì ÈÌÒ, ïîäîáíîå ïîëîæåíèå ïðèñóùå òàêæå áîëüíûì ñ çàñòîéíîé ñåðäå÷íîé íåäîñòàòî÷íîñòüþ (ÑÍ), îáñòðóêòèâíûìè çàáîëåâàíèÿìè ëåãêèõ, ðåâìàòîèäíûì àðòðèòîì, çëîêà÷åñòâåííûìè îïóõîëÿìè, ñòàðèêàì [30], ÂÈ×-èíôèöèðîâàííûì. Áîëåå òîãî, ñåé÷àñ ñòàëî èçâåñòíî, ÷òî îáðàòíàÿ ýïèäåìèîëîãèÿ õàðàêòåðíà è äëÿ áîëüíûõ ñ äîäèàëèçíîé ñòàäèåé ÕÏÍ [48]. Òàêèì îáðàçîì, ïîëó÷åííûå äàííûå òðåáóþò îáúÿñíåíèÿ. Èçâåñòíî, ÷òî äëÿ áîëüíûõ ñ ÑÍ, èìåþùèõ áîëüøóþ ìàññó òåëà, õàðàêòåðíî áîëåå âûñîêîå ñèñòåìíîå ÀÄ, ÷òî ïîâûøàåò òîëåðàíòíîñòü ê èçìåíåíèÿì îáúåìíîé íàãðóçêè íà ñåðäå÷íóþ ìûøöó. Îäíàêî íåîáõîäèìî ó÷èòûâàòü, ÷òî ýòè áîëüíûå ïðàêòè÷åñêè âñåãäà ïîëó÷àþò èíãèáèòîðû àíãèîòåíçèí-ïðåâðàùàþùåãî ôåðìåíòà, óâåëè÷èâàþùèå âûæèâàåìîñòü ïàöèåíòîâ ñ ÑÍ [34]. Ó áîëüíûõ ñ ÑÍ, íàõîäÿùèõñÿ íà äèàëèçå, ïîâûøåí óðîâåíü öèòîêèíà TNF-α, êîòîðûé, îáëàäàÿ ïðîàïîïòè÷åñêîé ñïîñîáíîñòüþ, ïîâðåæäàåò ñåðäå÷íóþ ìûøöó è âûçûâàåò îòðèöàòåëüíûé èíîòðîïíûé ýôôåêò [23]. Ó ëèö ñ îæèðåíèåì ôóíêöèîíèðîâàíèå ñèñòåìû TNF-α èçìåíÿåòñÿ. Æèðîâàÿ òêàíü ïðîäóöèðóåò âîäîðàñòâîðèìûå ðåöåïòîðû TNF-α, â ðåçóëüòàòå ÷åãî èõ êîíöåíòðàöèÿ óâåëè÷èâàåòñÿ [57]. Áëàãîäàðÿ íåéòðàëèçàöèè TNF-α óñòðàíÿåòñÿ íåãàòèâíîå âëèÿíèå öèòîêèíà íà ñåðäå÷íóþ ìûøöó. Îáíàðóæåíî, ÷òî ó áîëüíûõ ñ ïîâûøåííûì âåñîì èçìåíÿåòñÿ ôóíêöèîíèðîâàíèå ñèìïàòè÷åñêîé íåðâíîé (ÑÍÑ) è ðåíèí-àíãèîòåíçèíîâîé ñèñòåì (ÐÀÑ). Òàê, â èññëåäîâàíèè M.A. Weber ñ ñîàâò. [90] áûëî ïîêàçàíî, ÷òî ïðè ôèçè÷åñêîé íàãðóçêå (òðåäìèë-òåñò) ó Àäðåñ äëÿ ïåðåïèñêè: 125101, ã. Ìîñêâà, 2-é Áîòêèíñêèé ïð-ä, ä. 5. ÃÊÁ èì. Ñ.Ï. Áîòêèíà, îòäåëåíèå äèàëèçà Ò. 10, ¹ 34 2008 · Íåôðîëîãèÿ è äèàëèç 199 Îáçîðû è ëåêöèè áîëüíûõ ñ àðòåðèàëüíîé ãèïåðòåíçèåé è ÈÌÒ > 30 êîíöåíòðàöèÿ ðåíèíà â êðîâè ïîâûñèëàñü íà 65%, â òî âðåìÿ êàê ó ïàöèåíòîâ ñ ÈÌÒ < 25 íà 145%, êîíöåíòðàöèÿ íîðàäðåíàëèíà óâåëè÷èëàñü íà 200 è 500% ñîîòâåòñòâåííî. Ïîëó÷åííûå äàííûå ñâèäåòåëüñòâóþò î ëó÷øåé ïåðåíîñèìîñòè ñòðåññîâûõ ñèòóàöèé áîëüíûìè ñ èçáûòî÷íîé ìàññîé òåëà. Ïîâûøåííàÿ àêòèâàöèÿ ÑÍÑ è ÐÀÑ ñîïðîâîæäàåòñÿ õóäøåé âûæèâàåìîñòüþ ó áîëüíûõ ñ ÑÍ íà äèàëèçå [75]. Ó áîëüíûõ ñ ïîâûøåííîé ìàññîé òåëà âûÿâëÿåòñÿ áîëåå âûñîêèé óðîâåíü ëèïèäîâ è ëèïîïðîòåèíîâ, à íèçêèå óðîâíè ñûâîðîòî÷íîãî õîëåñòåðèíà è ëèïîïðîòåèíîâ àññîöèèðóþòñÿ ñ âûñîêîé ëåòàëüíîñòüþ ó áîëüíûõ ñ ÑÑÇ [66] è òåðìèíàëüíîé ÕÏÍ [61]. Ïîâûøåííûé óðîâåíü ëèïîïîëèñàõàðèäîâ, ïðèñóùèé áîëüíûì ñ ãèïåðãèäðàòàöèåé, ÑÍ è áîëüíûì, íàõîäÿùèìñÿ íà ÇÏÒ, ìîæåò ñïîñîáñòâîâàòü àêòèâàöèè èììóííîãî âîñïàëåíèÿ, ïîâûøåíèþ óðîâíÿ öèòîêèíîâ [60]. Ëèïîïðîòåèíû, ñâÿçûâàÿñü ñ ýíäîòîêñèíàìè, âûâîäÿò èõ èç îðãàíèçìà, ñïîñîáñòâóÿ ñíèæåíèþ óðîâíÿ ñèñòåìíîãî âîñïàëåíèÿ è áîëåå ïîçäíåìó ðàçâèòèþ àòåðîñêëåðîçà. Òàêèì îáðàçîì, ñíèæåíèå óðîâíÿ ëèïîïðîòåèíîâ íèæå îïðåäåëåííîãî óðîâíÿ ìîæåò áûòü áîëåå âðåäíûì, ÷åì èõ ïîâûøåííîå ñîäåðæàíèå [67]. Åùå îäíîé ïðè÷èíîé, îáúÿñíÿþùåé îáðàòíóþ ýïèäåìèîëîãèþ â âûæèâàåìîñòè ïàöèåíòîâ ñ óâåëè÷åííîé ìàññîé òåëà, ìîæåò áûòü ðàçíàÿ ñêîðîñòü ïðîÿâëåíèÿ íåãàòèâíûõ ïîñëåäñòâèé îò íåäîñòàòî÷íîñòè ïèòàíèÿ è îæèðåíèÿ. Áîëüøèíñòâî áîëüíûõ íà äèàëèçå æèâóò íå î÷åíü áîëüøîé ïåðèîä âðåìåíè, è îòðèöàòåëüíûå ïîñëåäñòâèÿ îæèðåíèÿ ÷àñòî íå óñïåâàþò ðàçâèòüñÿ. Âîçìîæíî, ÷òî âåëè÷èíà ÈÌÒ íå âñåãäà ïðè÷èíà, à ñêîðåå ñëåäñòâèå îáùåãî íåóäîâëåòâîðèòåëüíîãî ñîñòîÿíèÿ áîëüíûõ (íàïðèìåð, ïðè íàëè÷èè òÿæåëîé ñîïóòñòâóþùåé ïàòîëîãèè), ïðèâîäÿùåãî ê ïëîõèì èñõîäàì íà äèàëèçå. Òåì íå ìåíåå íàäî èìåòü â âèäó, ÷òî óâåëè÷åíèå ìàññû òåëà óëó÷øàåò âûæèâàåìîñòü íåçàâèñèìî îò ïðè÷èííî-ñëåäñòâåííîé ñâÿçè. Ïîñëåäíèå ïðîâåäåííûå èññëåäîâàíèÿ ïîêàçàëè ñíèæåíèå ëåòàëüíîñòè íå òîëüêî â äèàëèçíîé ãðóïïå ïàöèåíòîâ, íî è â îáùåé ïîïóëÿöèè áîëüíûõ ñ ÑÑÇ ó ëèö ñ âûñîêîé ìàññîé òåëà [12]. Àíàëèç 40 ðàáîò, ïîñâÿùåííûõ âçàèìîñâÿçè ðèñêà ñìåðòíîñòè ñ ÈÌÒ ó 250 152 ïàöèåíòîâ, ïîêàçàë ïîâûøåíèå îòíîñèòåëüíîãî ðèñêà îáùåé ëåòàëüíîñòè, ñâÿçàííîé ñ ñåðäå÷íî-ñîñóäèñòîé ëåòàëüíîñòüþ ó ëèö ñ ÈÌÒ < 20. Ó ëþäåé ñ ÈÌÒ 2529,9 îòíîñèòåëüíûå ðèñêè îáùåé ëåòàëüíîñòè è ñìåðòíîñòè îò ÑÑÇ áûëè íèæå ïî ñðàâíåíèþ ñ ëèöàìè, èìåþùèìè íîðìàëüíûé ÈÌÒ [70].  ãåíåçå ëåòàëüíîñòè ó áîëüíûõ ñ ÒÕÏÍ ïåðâîå ìåñòî çàíèìàþò êàðäèîâàñêóëÿðíûå çàáîëåâàíèÿ. Ïðè÷èíû, ñïîñîáñòâóþùèå ðàçâèòèþ àòåðîñêëåðîçà ó ýòèõ áîëüíûõ, òàêèå æå, êàê è â îáùåé ïîïóëÿöèè: äèñëèïèäåìèÿ, ãèïåðòåíçèÿ, êóðåíèå, ñàõàðíûé äèàáåò. Îäíàêî êëþ÷åâîå çíà÷åíèå â ðàçâèòèè àòåðîñêëåðîçà, êàê áûëî ïîêàçàíî â ïîñëåäíèå ãîäû, ïðèäàåòñÿ ïðîöåññó âîñïàëåíèÿ êàê â îáùåé ïîïóëÿöèè, òàê è ó áîëüíûõ ñ ÒÕÏÍ [71]. Ñèíäðîì âîñïàëåíèÿ, ñïîñîáñòâóÿ ðàçâèòèþ àòåðîñêëåðîçà è íàðóøåíèþ íóòðèöèîííîãî ñòàòóñà, ôîðìèðóåò MIA (malnutrition, inflammation, atherosclerosis) ñèíäðîì. Èçâåñòíî, ÷òî ïîòðåáëåíèå ïèùè ñ ïîâûøåííûì ñîäåðæàíèåì õîëåñòåðèíà ó çäîðîâûõ äîáðîâîëüöåâ íå ïðèâîäèò ê ðàçâèòèþ àòåðîñêëåðîçà, 200 Íåôðîëîãèÿ è äèàëèç · Ò. 10, ¹ 34 2008 Å.Â. Øóòîâ Òà á ë è ö à 1 Âîçìîæíûå ìåõàíèçìû îáðàòíîé ýïèäåìèîëîãèè ó ëèö ñ ïîâûøåííîé ìàññîé òåëà 1. Âðåìåííûå ðàçëè÷èÿ â îòðèöàòåëüíîì âëèÿíèè íåäîñòàòî÷íîñòè íóòðèòèâíîãî ñòàòóñà è ïîâûøåííîé ìàññû òåëà 2. Îáðàòíàÿ çàâèñèìîñòü ìåæäó ÈÌÒ è èñõîäàìè 3. Íàëè÷èå ñèíäðîìà âîñïàëåíèÿ è íåäîñòàòî÷íîñòè ïèòàíèÿ 4. Ýíäîòîêñèí-ëèïîïðîòåèíîâàÿ ãèïîòåçà 5. Áîëåå ñòàáèëüíûé ãåìîäèíàìè÷åñêèé ñòàòóñ ó áîëüíûõ ñ îæèðåíèåì 6. Ïîâûøåíèå ÷èñëà âîäîðàñòâîðèìûõ ðåöåïòîðîâ TNF-α 7. Èçìåíåíèÿ ôóíêöèîíèðîâàíèÿ íåðâíîé è ýíäîêðèííîé ñèñòåì 8. Èçìåíåíèÿ òðàäèöèîííûõ ôàêòîðîâ ðèñêà ó áîëüíûõ ñ ÕÏÍ 9. Ñíèæåííûé óðîâåíü Â-òèïà íàòðèéóðåòè÷åñêîãî ãîðìîíà âñêðûòèå æå òðóïîâ óçíèêîâ êîíöëàãåðåé, ñòðàäàâøèõ êðàéíåé ñòåïåíüþ èñòîùåíèÿ, ïîêàçàëî òÿæåëûå àòåðîñêëåðîòè÷åñêèå ïîâðåæäåíèÿ ñîñóäîâ. Ó÷àùåíèå ñëó÷àåâ ñìåðòè â ðåçóëüòàòå ÑÑÇ ó áîëüíûõ ñ íåäîñòàòî÷íîñòüþ ïèòàíèÿ è ãèïîòîíèåé ñâÿçàíî ñ ýíäîòåëèàëüíîé äèñôóíêöèåé, ïðèâîäÿùåé ê ïîâûøåíèþ êîàãóëÿöèè, àêòèâàöèè òðîìáîöèòîâ, ëåéêîöèòîâ, ðàçâèòèþ îñòðûõ êîðîíàðíûõ òðîìáîçîâ è, êàê ñëåäñòâèå, èøåìè÷åñêèì ïîâðåæäåíèÿì ìèîêàðäà [63]. Íåäàâíèå èññëåäîâàíèÿ òàêæå ïîêàçàëè, ÷òî ó áîëüíûõ ñ îæèðåíèåì íèæå óðîâåíü Â-íàòðèéóðåòè÷åñêîãî ïåïòèäà (ÂNP) íåçàâèñèìîãî ïðåäèêòîðà ëåòàëüíîñòè áîëüíûõ ñ ñåðäå÷íîé íåäîñòàòî÷íîñòüþ [33]. Áîëåå òîãî, èìååòñÿ îáðàòíàÿ êîððåëÿöèÿ ìåæäó êîíöåíòðàöèåé ãåìîãëîáèíà è BNP. Ìåõàíèçìû ñíèæåííîãî ñîäåðæàíèÿ BNP ó ëèö ñ ïîâûøåííûì âåñîì ñëåäóþùèå: 1) áîëåå íèçêèé óðîâåíü TNF-α, áëàãîäàðÿ ÷åìó èç êàðäèîìèîöèòîâ èçâëåêàåòñÿ ìåíüøå BNP; 2) óâåëè÷åíèå äåãðàäàöèè BNP íåéòðàëüíûìè ýíäîïåïòèäàçàìè æèðîâîé òêàíè; 3) óìåíüøåíèå öèðêóëÿöèè BNP èç-çà îæèðåíèÿ; 4) ïîâûøåíèå êëèðåíñà BNP. È íàêîíåö, âñå ïðåäûäóùèå äàííûå èñòîðèè ÷åëîâå÷åñòâà ñâèäåòåëüñòâóþò î ëó÷øåé âûæèâàåìîñòè ëþäåé ñ ïîâûøåííîé ìàññîé òåëà ïî ñðàâíåíèþ ñ ëèöàìè ñ íåäîñòàòî÷íîñòüþ ïèòàíèÿ.  íàñòîÿùåå âðåìÿ â ðàçâèòûõ ñòðàíàõ, íåñìîòðÿ íà ïðîáëåìû, êîòîðûå âîçíèêàþò â ñâÿçè ñ ðåçêèì óâåëè÷åíèåì ÷èñëà ëþäåé ñ îæèðåíèåì, ïðîäîëæèòåëüíîñòü æèçíè âûøå, ÷åì â ðàçâèâàþùèõñÿ ñòðàíàõ. Òàêèì îáðàçîì, ìîæíî ñäåëàòü âûâîä, ÷òî ðåêîìåíäàöèè ïî îïòèìàëüíîìó âåñó, óðîâíþ õîëåñòåðèíà è àðòåðèàëüíîãî äàâëåíèÿ, ïî êðàéíåé ìåðå ó áîëüíûõ ñ òÿæåëûìè õðîíè÷åñêèìè çàáîëåâàíèÿìè, äîëæíû áûòü îòëè÷íûìè îò îáùåïîïóëÿöèîííûõ äàííûõ. Ïðè÷èíû îáðàòíîé ýïèäåìèîëîãèè ó áîëüíûõ ñ ïîâûøåííîé ìàññîé òåëà ïðåäñòàâëåíû â òàáë. 1. Ïðè÷èíû íàðóøåíèÿ íóòðèòèâíîãî ñòàòóñà ó áîëüíûõ ñ êîíñåðâàòèâíîé ñòàäèåé ÕÏÍ Ê íàðóøåíèþ íóòðèòèâíîãî ñòàòóñà ó áîëüíûõ ñ ÕÏÍ ïðèâîäèò ìíîæåñòâî ïðè÷èí (òàáë. 2).  ðåçóëüòàòå óðåìè÷åñêîé èíòîêñèêàöèè ñíèæàåòñÿ àïïåòèò, Íóòðèòèâíûé ñòàòóñ ó áîëüíûõ ñ õðîíè÷åñêîé ïî÷å÷íîé íåäîñòàòî÷íîñòüþ Òà á ë è ö à 2 Ïðè÷èíû íàðóøåíèÿ íóòðèòèâíîãî ñòàòóñà ó áîëüíûõ ñ êîíñåðâàòèâíîé ÕÏÍ 1. Ñíèæåíèå àïïåòèòà è ïîòðåáëåíèÿ ïèùè 2. Óðåìè÷åñêàÿ èíòîêñèêàöèÿ 3. Æåëóäî÷íî-êèøå÷íûå ôàêòîðû 4. Ýíäîêðèííûå ôàêòîðû 5. Ìåòàáîëè÷åñêèé àöèäîç 6. Ñèíäðîì õðîíè÷åñêîãî âîñïàëåíèÿ 7. Ñîïóòñòâóþùèå çàáîëåâàíèÿ 8. Ïîæèëîé âîçðàñò 9. Ïñèõîëîãè÷åñêèå (äåïðåññèÿ) è ñîöèîýêîíîìè÷åñêèå ôàêòîðû (áåäíîñòü, îäèíî÷åñòâî) 10. Ñíèæåíèå ôèçè÷åñêîé àêòèâíîñòè ïîÿâëÿþòñÿ æåëóäî÷íî-êèøå÷íûå ðàññòðîéñòâà, ïðèâîäÿùèå ê ñíèæåíèþ ïîòðåáëåíèÿ ïèùè [64]. Íàáëþäàåòñÿ ïðÿìàÿ êîððåëÿöèÿ ìåæäó ñòåïåíüþ ïî÷å÷íîé íåäîñòàòî÷íîñòè è ïîòðåáëåíèåì ïðîäóêòîâ ïèòàíèÿ [46]. Óõóäøåíèå ôóíêöèé æåëóäî÷íî-êèøå÷íîãî òðàêòà òàêæå ñïîñîáñòâóåò íàðóøåíèþ íóòðèòèâíîãî ñòàòóñà: âîçíèêàþò ðàññòðîéñòâà ïèùåâàðåíèÿ è âñàñûâàíèÿ, íàðóøàåòñÿ ìîòîðèêà æåëóäêà è êèøå÷íèêà, óõóäøàåòñÿ ñåêðåöèÿ æåë÷è è ôåðìåíòîâ ïîäæåëóäî÷íîé æåëåçû. Ïðè íàëè÷èè äèàáåòà ÷àñòî âñòðå÷àþòñÿ ãàñòðîïàðåç è íàðóøåíèå ïåðèñòàëüòèêè êèøå÷íèêà. Ó 3050% áîëüíûõ ñ ïðåääèàëèçíîé ÕÏÍ èìååòñÿ ñèíäðîì õðîíè÷åñêîãî ñèñòåìíîãî âîñïàëåíèÿ [80], êîòîðûé ñîïðîâîæäàåòñÿ ïîâûøåíèåì êîíöåíòðàöèè ïðîâîñïàëèòåëüíûõ öèòîêèíîâ è, â ñâîþ î÷åðåäü, óñèëèâàåò êàòàáîëèçì, ïðèâîäèò ê ïîòåðå àïïåòèòà. Êðîìå òîãî, óìåíüøåíèå äèóðåçà è ïîÿâëåíèå ó áîëüíûõ ãèïåðãèäðàòàöèè òàêæå ñïîñîáñòâóåò âîçíèêíîâåíèþ ñèíäðîìà âîñïàëåíèÿ [39, 60] è íåäîñòàòî÷íîñòè ïèòàíèÿ [16]. Áîëüíûå ñ ÒÕÏÍ â ñâÿçè ñî ñíèæåííûì èììóíèòåòîì ÷àñòî ñòðàäàþò èíòåðêóððåíòíûìè èíôåêöèîííûìè çàáîëåâàíèÿìè, äëÿ íèõ õàðàêòåðíî íàëè÷èå ñèíäðîìà õðîíè÷åñêîãî âîñïàëåíèÿ, êîòîðûé âûçûâàåò óñèëåíèå êàòàáîëèçìà áåëêîâ. Ýíäîêðèííûå íàðóøåíèÿ, âîçíèêàþùèå ïðè óðåìèè, â ÷àñòíîñòè ïîâûøåíèå óðîâíÿ ãëþêàãîíà è ïàðàòèðåîèäíîãî ãîðìîíà, òàêæå ïðèâîäÿò ê ïîâûøåíèþ êàòàáîëèçìà [58, 76]. Ãèïåðïàðàòèðåîèäèçì, ñîïðîâîæäàþùèé ÕÏÍ, ñïîñîáñòâóåò óìåíüøåíèþ ñåêðåöèè èíñóëèíà ïîäæåëóäî÷íîé æåëåçîé è ïîâûøàåò ãëþêîãåíåç. Åùå îäíîé èç ïðè÷èí âûñîêîãî êàòàáîëèçìà ïðè ÕÏÍ ÿâëÿåòñÿ ðàçâèòèå ìåòàáîëè÷åñêîãî àöèäîçà, ñïîñîáñòâóþùåãî ñóïðåññèè ñèíòåçà àëüáóìèíà, îêèñëåíèþ àìèíîêèñëîò è îñâîáîæäåíèþ èíñóëèíîïîäîáíîãî ôàêòîðà ðîñòà-1 (ÈÏÔÐ-1) [9, 68]. Îäíàêî íóòðèöèîííûé ñòàòóñ ó áîëüíûõ ñ ÒÕÏÍ ñòðàäàåò äàæå ïðè íîðìàëüíîì óðîâíå ÈÏÔÐ-1, òàê êàê åãî áèîàêòèâíîñòü ñíèæåíà ïî ñðàâíåíèþ ñî çäîðîâûìè ëèöàìè [11]. Ñ÷èòàþò, ÷òî ýòî ñâÿçàíî ñ ïîâûøåííûì óðîâíåì ïðîòåèíîâ 35 êÄà, ñâÿçûâàþùèõ ÈÏÔÐ. Ïðèìåíåíèå ðåêîìáèíàíòíîãî ÷åëîâå÷åñêîãî ãîðìîíà ðîñòà ïîçâîëÿåò óâåëè÷èòü êîíöåíòðàöèþ ãîðìîíà ðîñòà è ïðåîäîëåòü ðåçèñòåíòíîñòü, ñâÿçàííóþ ñ èíãèáèòîðíûì äåéñòâèåì áåëêîâ, ñâÿçûâàþùèõ ÈÏÔÐ [65]. Õàðàêòåðíàÿ äëÿ óðåìèè èíñóëèíîðåçèñòåíòíîñòü ñïîñîáñòâóåò ñíèæåíèþ òîùåé ìàññû âñëåäñòâèå àêòèâàöèè ïðîòåîëèçà ÷åðåç êàñïàçó-3 è óáèêâèòèíïðîòåàñîì-ïðîòåîëèòè÷åñêèé ïóòü (UPP) â ìûøöàõ Îáçîðû è ëåêöèè [53], ñóïðåññèðóÿ ôîñôàòèäèëèíîçèòîë-3-êèíàçó [89]. Ïðè÷èíû æå âîçíèêíîâåíèÿ ðåçèñòåíòíîñòè ê èíñóëèíó è ÈÏÔÐ-1 ïðè ÕÏÍ îêîí÷àòåëüíî íå ÿñíû. Íàïðèìåð, F. Cecchin ñ ñîàâò. [15] âûÿâèëè ñíèæåíèå èíñóëèíîâûõ ðåöåïòîðîâ è èõ ñâÿçûâàþùåé ñïîñîáíîñòè, L. Bailey c ñîàâò. [38] äåôåêòû â ñèñòåìå ñèãíàëèçàöèè ñóáñòðàòà èíñóëèíîâûõ ðåöåïòîðîâ, L. Rui ñ ñîàâò. è G.S. Hotamisligil ñ ñîàâò. [35, 72] ïîâûøåíèå óðîâíÿ öèòîêèíîâ è ò. ä. Ó áîëüíûõ ñ ÕÏÍ íàáëþäàåòñÿ ïîâûøåííûé óðîâåíü ëåïòèíà â êðîâè [26]. Íåäàâíèå äëèòåëüíûå èññëåäîâàíèÿ ïîêàçàëè, ÷òî ïîâûøåíèå óðîâíÿ ëåïòèíà àññîöèèðóåòñÿ ñ ïîòåðåé ìàññû òåëà ó áîëüíûõ íà ÃÄ [62] è ÏÄ [81]. Ïðè÷èíàìè ãèïåðëåïòèíåìèè ïðè ÕÏÍ ÿâëÿþòñÿ: íàêîïëåíèå ýòîãî ïîëèïåïòèäà èç-çà ñíèæåíèÿ ôèëüòðàöèè åãî ïî÷êàìè [81]; ñòèìóëÿöèÿ ñèíòåçà ëåïòèíà èíñóëèíîì [79]; àêòèâàöèÿ ñèíòåçà ëåïòèíà ïðè âîñïàëåíèè [81]. Ó áîëüíûõ ñ ÕÏÍ ÷àñòî èìåþòñÿ ñîïóòñòâóþùèå çàáîëåâàíèÿ: íàïðèìåð, ó òðåòè ïàöèåíòîâ âñòðå÷àþòñÿ êàðäèîâàñêóëÿðíûå áîëåçíè, à ñàõàðíûé äèàáåò ïðèâîäèò ê ðàçâèòèþ òåðìèíàëüíîé ÕÏÍ è íà÷àëó ÇÏÒ ó 50% ïàöèåíòîâ â ÑØÀ [86]. Ïðîãðåññèâíî óâåëè÷èâàåòñÿ ÷èñëî áîëüíûõ ñòàðøåãî âîçðàñòà (>65 ëåò), ó êîòîðûõ ñíèæåíà ôèçè÷åñêàÿ àêòèâíîñòü. Âñå âûøåïåðå÷èñëåííîå ñïîñîáñòâóåò óõóäøåíèþ íóòðèöèîííîãî ñòàòóñà. Äî ñèõ ïîð èìåþò çíà÷åíèå â ðàçâèòèè íåäîñòàòî÷íîñòè ïèòàíèÿ è ñîöèîýêîíîìè÷åñêèå ôàêòîðû: áåäíîñòü, îäèíî÷åñòâî è ÷àñòî ñîïðîâîæäàþùàÿ èõ äåïðåññèÿ. Ó áîëüíûõ, ïîëó÷àþùèõ ïðîãðàììíûé ãåìîäèàëèç, íàðóøåíèÿ íóòðèöèîííîãî ñòàòóñà âñòðå÷àþòñÿ åùå ÷àùå, ÷òî îáóñëîâëåíî äîïîëíèòåëüíûìè ïðè÷èíàìè (òàáë. 3). Îòìå÷åíî, ÷òî ñ óìåíüøåíèåì ðåíàëüíîãî êëèðåíñà ïîâûøàåòñÿ óðîâåíü ïðîâîñïàëèòåëüíûõ öèòîêèíîâ [32]. Ïðîöåäóðà ãåìîäèàëèçà, êîòîðàÿ îñíîâàíà íà ýêñòðàêîðïîðàëüíîé öèðêóëÿöèè êðîâè, ñîïðîâîæäàþùåéñÿ êîíòàêòîì êðîâè áîëüíîãî ñ äèàëèçíîé ìåìáðàíîé, ñïîñîáñòâóåò âîçíèêíîâåíèþ ñèíäðîìà âîñïàëåíèÿ. Îñîáåííî ïîâûøàåòñÿ óðîâåíü öèòîêèíîâ ïðè èñïîëüçîâàíèè áèîíåñîâìåñòèìûõ ìåìáðàí [52] è íåñòåðèëüíîãî äèàëèçàòà [83]. Êàæäàÿ ïðîöåäóðà ãåìîäèàëèçà ñîïðîâîæäàåòñÿ ïîòåðåé àìèíîêèñëîò îò 6 äî 12 ã [37] è 23 ã ïåïòèäîâ. Ïîòåðè àìèíîêèñëîò çàâèñÿò îò ïðîíèöàåìîñòè ìåìáðàí, ñêîðîñòè êðîâè è äèàëèçàòà, âðåìåíè ïðîöåäóðû. Êðîìå òîãî, ãåìîäèàëèç ñîïðîâîæäàåòñÿ ïîòåðåé èç îðãàíèçìà äî 26 ã ãëþêîçû ïðè èñïîëüçîâàíèè äèàëèçàòà, íå ñîäåðæàùåãî ãëþêîçó [31]. Óäàëåíèå âîäîðàñòâîðèìûõ âèòàìèíîâ âî âðåìÿ ïðîöåäóðû íå î÷åíü çíà÷èòåëüíîå, òàê êàê ìîëåêóëÿðíàÿ ìàññà ýòèõ âåùåñòâ äîñòàòî÷íî áîëüøàÿ, áîëüøå ìíîãèõ àìèíîêèñëîò.  íåÒà á ë è ö à 3 Äîïîëíèòåëüíûå ôàêòîðû, ñïîñîáñòâóþùèå ðàçâèòèþ íåäîñòàòî÷íîñòè ïèòàíèÿ ó áîëüíûõ íà ãåìîäèàëèçå 1. Áîëåå âûðàæåííàÿ àíîðåêñèÿ, ÷åì â äîäèàëèçíûé ïåðèîä 2. Íåàäåêâàòíûé äèàëèç 3. Áîëåå âûðàæåííûé óðåìè÷åñêèé ñèíäðîì 4. Âîñïàëåíèå, àêòèâàöèÿ êàòàáîëèçìà ïðè äèàëèçå 5. Ïîòåðÿ àìèíîêèñëîò, âèòàìèíîâ è êàðíèòèíà Ò. 10, ¹ 34 2008 · Íåôðîëîãèÿ è äèàëèç 201 Îáçîðû è ëåêöèè áîëüøîì êîëè÷åñòâå óäàëÿþòñÿ âèòàìèí Â1, Â2 è Â6, àñêîðáèíîâàÿ è ôîëèåâàÿ êèñëîòû è ñîâñåì íåçíà÷èòåëüíî âèòàìèí Â12. Íàäî îòìåòèòü òàêæå, ÷òî ýíåðãåòè÷åñêèå çàòðàòû ó áîëüíûõ íà ãåìîäèàëèçå íåñêîëüêî âûøå, ÷åì ó çäîðîâûõ [59]. Ó áîëüíûõ ñ ÒÕÏÍ, ïîëó÷àþùèõ ïåðèòîíåàëüíûé äèàëèç, òàêæå èìåþòñÿ äîïîëíèòåëüíûå ôàêòîðû, ñïîñîáñòâóþùèå âîçíèêíîâåíèþ íåäîñòàòî÷íîñòè ïèòàíèÿ. Òàê, åñëè ïîòåðè àìèíîêèñëîò ïðè ïåðèòîíåàëüíîì äèàëèçå ñðàâíèìû ñ ãåìîäèàëèçîì, òî ñóòî÷íûå ïîòåðè áåëêà çíà÷èòåëüíî âûøå è ñîñòàâëÿþò 315 ã â ñóòêè. Ïîòåðè áåëêà ïðèâîäÿò íå òîëüêî ê íàðóøåíèþ íóòðèöèîííîãî ñòàòóñà, íî è ê âîçíèêíîâåíèþ äèñëèïèäåìèè. Íàäî çàìåòèòü, ÷òî ó áîëüíûõ, èìåþùèõ âûñîêóþ ïðîíèöàåìîñòü áðþøèíû èç-çà ïîâûøåííûõ ïîòåðü íóòðèåíòîâ â äèàëèçàò è ñíèæåííûé àïïåòèò (â ðåçóëüòàòå ïîâûøåííîãî âñàñûâàíèÿ ãëþêîçû), ÷àùå âîçíèêàåò íåäîñòàòî÷íîñòü ïèòàíèÿ, ÷åì ó ïàöèåíòîâ ñ íèçêîïðîíèöàåìîé áðþøèíîé. Îñîáåííî ñèëüíî ïîâðåæäàåòñÿ áðþøèíà âî âðåìÿ ïåðèòîíèòà, êîãäà ïîòåðè áåëêà âîçðàñòàþò â 23 ðàçà, ÷òî íåãàòèâíî ñêàçûâàåòñÿ íà íóòðèòèâíîì ñòàòóñå ïàöèåíòà. Êðîìå òîãî, ïðè äèàëèçíîì ïåðèòîíèòå ïîâûøàåòñÿ ñîäåðæàíèå öèòîêèíîâ, óâåëè÷èâàåòñÿ êàòàáîëèçì [4]. Ó áîëüíûõ íà ÏÄ ïðè èñïîëüçîâàíèè äèàëèçíûõ ðàñòâîðîâ, ñîäåðæàùèõ ãëþêîçó, â ñâÿçè ñ åå ðåàáñîðáöèåé îò 100 äî 300 ã â ñóòêè âîçíèêàåò ëîæíîå ÷óâñòâî ñûòîñòè è êàê ñëåäñòâèå ñíèæåíèå àïïåòèòà. Äîïîëíèòåëüíûì ôàêòîðîì, îãðàíè÷èâàþùèì ïîòðåáëåíèå ïèùè ó áîëüíûõ íà ÏÄ, ÿâëÿåòñÿ íàõîæäåíèå äèàëèçàòà îáúåìîì 23 ë â áðþøíîé ïîëîñòè, ïðèâîäÿùåå ê ïîâûøåíèþ èíòðààáäîìèíàëüíîãî äàâëåíèÿ è îùóùåíèþ ïîëíîãî æèâîòà. Áûëî ïîêàçàíî, ÷òî áîëüíûå, íàõîäÿùèåñÿ íà ÏÄ, ïîòðåáëÿþò çà 1 ïðèåì â 1,52 ðàçà ìåíüøèé îáúåì ïèùè, ÷åì çäîðîâûå ëþäè [36]. Åñëè ïðîñëåäèòü äèíàìèêó íóòðèöèîííûõ íàðóøåíèé ó ïàöèåíòîâ íà ÏÄ, ìîæíî îòìåòèòü, ÷òî â ïåðâûå ãîäû äèàëèçà âåñ è æèðîâàÿ ìàññà óâåëè÷èâàþòñÿ â ïåðâóþ î÷åðåäü çà ñ÷åò àáñîðáöèè ãëþêîçû èç Òà á ë è ö à 4 Äîïîëíèòåëüíûå ôàêòîðû, ñïîñîáñòâóþùèå ðàçâèòèþ íåäîñòàòî÷íîñòè ïèòàíèÿ ó áîëüíûõ, ïîëó÷àþùèõ ïåðèòîíåàëüíûé äèàëèç 1. Ïîòåðÿ àìèíîêèñëîò (13,5 ã), âèòàìèíîâ è áåëêà (515 ã) 2. Àáñîðáöèÿ ãëþêîçû 3. Ëîæíîå ÷óâñòâî ñûòîñòè èç-çà äèàëèçàòà â áðþøíîé ïîëîñòè 4. Âîñïàëåíèå, èíôåêöèè (ïåðèòîíèòû è äð.) 5. Âûñîêàÿ ïðîíèöàåìîñòü áðþøèíû 6. Ïîâûøåíèå óðîâíÿ öèòîêèíîâ Òà á ë è ö à 5 Òèïû íàðóøåíèÿ íóòðèòèâíîãî ñòàòóñà Õàðàêòåðíûå ïðèçíàêè Òèï 1 Òèï 2 Ñèíäðîì âîñïàëåíèÿ Íåò Èìååòñÿ Êàòàáîëèçì áåëêîâ Ñíèæåí Ïîâûøåí Ñîïóòñòâóþùèå çàáîëåâàíèÿ ×àùå íåò Õàðàêòåðíû Ñûâîðîòî÷íûé àëüáóìèí Íîðìà/ñíèæåí Ñíèæåí Êîððåêòèðóåòñÿ ïðèåìîì Äà Íåò ïèùè, óâåëè÷åíèåì äîçû äèàëèçà 202 Íåôðîëîãèÿ è äèàëèç · Ò. 10, ¹ 34 2008 Å.Â. Øóòîâ äèàëèçàòà, à òàêæå çà ñ÷åò ñíèæåíèÿ ôèçè÷åñêîé àêòèâíîñòè.  äàëüíåéøåì ïîä âîçäåéñòâèåì áèîíåñîâìåñòèìûõ äèàëèçíûõ ðàñòâîðîâ ïðîíèöàåìîñòü áðþøèíû âîçðàñòàåò, ÷òî ïðèâîäèò ê óâåëè÷åíèþ ïîòåðè áåëêà, àìèíîêèñëîò, ýëåêòðîëèòîâ è âèòàìèíîâ è ñïîñîáñòâóåò âîçíèêíîâåíèþ ñèíäðîìà íåäîñòàòî÷íîñòè ïèòàíèÿ. Äîïîëíèòåëüíûå ôàêòîðû, ïðèâîäÿùèå ê íàðóøåíèþ íóòðèòèâíîãî ñòàòóñà ó áîëüíûõ íà ÏÄ, ïðåäñòàâëåíû òàáë. 4. Âûäåëÿþò 2 òèïà íåäîñòàòî÷íîñòè ïèòàíèÿ ó áîëüíûõ ñ ÕÏÍ [78] (òàáë. 5). Òèï 1 àññîöèèðóåòñÿ ñ óðåìèåé, ñíèæåíèåì ïîòðåáëåíèÿ ïèùè è ôèçè÷åñêîé àêòèâíîñòè, äåïðåññèåé. Äëÿ äàííîãî òèïà õàðàêòåðíî íàðóøåíèå áåëêîâîãî àíàáîëèçìà, äèñôóíêöèÿ àíàáîëè÷åñêèõ ãîðìîíîâ. Äëÿ 2-ãî òèïà õàðàêòåðíî íàëè÷èå ó áîëüíîãî ñèíäðîìà âîñïàëåíèÿ, ñîïóòñòâóþùèõ çàáîëåâàíèé, ïîâûøåííîãî êàòàáîëèçìà áåëêîâ. Îöåíêà íóòðèöèîííîãî ñòàòóñà Îïðåäåëèòü ñîñòîÿíèå íóòðèöèîííîãî ñòàòóñà ñ ïîìîùüþ îäíîãî ïîêàçàòåëÿ íåâîçìîæíî. Äëÿ îöåíêè ñîñòîÿíèÿ ïèòàíèÿ èñïîëüçóþò ñëåäóþùèå ìåòîäû èññëåäîâàíèÿ: àíàìíåç è ôèçèêàëüíûé îñìîòð; àíòðîïîìåòðèþ; ëàáîðàòîðíûå ïîêàçàòåëè, èììóíîëîãè÷åñêèå è ôóíêöèîíàëüíûå äàííûå. Øèðîêî ïðèìåíÿþò òàêæå ìåòîä ñóáúåêòèâíîé ãëîáàëüíîé îöåíêè (ÑÃÎ), áàçèðóþùèéñÿ íà àíàìíåçå è ôèçèêàëüíîì îñìîòðå. Ýòîò ìåòîä ðåêîìåíäîâàí íàöèîíàëüíûì ïî÷å÷íûì ôîíäîì ÑØÀ. Ñïîñîá èçíà÷àëüíî áûë ðàçðàáîòàí äëÿ îöåíêè íóòðèòèâíîãî ñòàòóñà áîëüíûõ â ïðåäîïåðàöèîííîì ïåðèîäå [19]. Äëÿ áîëüíûõ íà äèàëèçå îöåíêà âêëþ÷àåò 4 ïàðàìåòðà [22]: 1) ïîòåðþ âåñà; 2) èçìåíåíèÿ â ïèòàíèè (îöåíêà äèåòû); 3) ïîòåðþ æèðîâîé ìàññû; 4) ïîòåðþ ìûøå÷íîé ìàññû. Ïî êàæäîìó èç ïàðàìåòðîâ ïðîâîäèòñÿ îöåíêà ïî 7-áàëëüíîé øêàëå: ÷åì ìåíüøå âûðàæåíû èçìåíåíèÿ, òåì íèæå áàëë. Ïîòåðÿ âåñà çà ïîñëåäíèå 6 ìåñ.: 10% è âûøå áîëüøàÿ (12 áàëëà); 510% ñðåäíÿÿ (35 áàëëîâ); äî 5% îòñóòñòâóåò èëè íåçíà÷èòåëüíàÿ (67 áàëëîâ). Èçìåíåíèÿ â ïèòàíèè: íàëè÷èå òîøíîòû è ðâîòû; èçìåíåíèå â äèåòå; ñíèæåíèå àïïåòèòà. Ïîòåðÿ æèðîâîé ìàññû: îïðåäåëÿåòñÿ ïî êîæíî-æèðîâûì ñêëàäêàì íàä áèöåïñîì è òðèöåïñîì, ïî íàëè÷èþ âïàäèí ïîä ãëàçàìè. Ïîòåðÿ ìûøå÷íîé ìàññû: îïðåäåëÿåòñÿ ïî òåìïîðàëüíûì è ÷åòûðåõãëàâîé ìûøöàì, êîíòóðó ïëå÷, âûñòóïàíèþ êëþ÷èö, ëîïàòîê, ðåáåð, ìåæêîñòíîé ìûøå÷íîé ìàññå ìåæäó áîëüøèì è óêàçàòåëüíûì ïàëüöàìè. Ðåçóëüòàò ñêëàäûâàåòñÿ èç 4 ÷èñåë, ïî êîòîðûì îöåíèâàåòñÿ ñòåïåíü íàðóøåíèÿ ïèòàíèÿ: îòñóòñòâèå; óìåðåííîå èëè òÿæåëîå íàðóøåíèå íóòðèöèîííîãî ñòàòóñà. Íàäî îòìåòèòü ñóáúåêòèâíîñòü ìåòîäà, òî÷íîñòü è âîñïðîèçâîäèìîñòü êîòîðîãî íèçêà. Òåì íå ìåíåå ó áîëüíûõ íà ÏÀÏÄ ñ òÿæåëûì íàðóøåíèåì ïèòàíèÿ, îïðåäåëåííûì ñ ïîìîùüþ ÑÃÎ, îòíîñèòåëüíûé ðèñê ñìåðòè áûë âûøå [6]. Àíòðîïîìåòðèÿ (ãðå÷. anthropos ÷åëîâåê + metre ìåðèòü, èçìåðÿòü) ñîâîêóïíîñòü ìåòîäè÷åñ- Íóòðèòèâíûé ñòàòóñ ó áîëüíûõ ñ õðîíè÷åñêîé ïî÷å÷íîé íåäîñòàòî÷íîñòüþ êèõ ïðèåìîâ â àíòðîïîëîãè÷åñêîì èññëåäîâàíèè. Àíòðîïîìåòðèÿ âêëþ÷àåò â ñåáÿ: èçìåðåíèå òåëà è åãî ÷àñòåé (ñîìàòîìåòðèþ), ñêåëåòà (îñòåîìåòðèþ, êðàíèîìåòðèþ), à òàêæå îïèñàíèå (àíòðîïîñêîïèþ) òåëà ÷åëîâåêà â öåëîì è îòäåëüíûõ åãî ÷àñòåé (ðàçâèòèÿ æèðîâîãî ñëîÿ, ìóñêóëàòóðû, ôîðìû ãðóäíîé êëåòêè, ñïèíû, æèâîòà, íîã, ïèãìåíòàöèè, âîëîñÿíîãî ïîêðîâà, âòîðè÷íûõ ïîëîâûõ ïðèçíàêîâ è äð.). Ó áîëüíûõ ñ ÕÏÍ ÷àùå âñåãî îïðåäåëÿþòñÿ ñëåäóþùèå ïàðàìåòðû: ðîñò, ìàññà òåëà, òîëùèíà êîæíî-æèðîâîé ñêëàäêè (ÊÆÑ) (ïîäëîïàòî÷íîé îáëàñòè, íàä òðèöåïñîì, áèöåïñîì, ïîäâçäîøíûì ãðåáíåì), îêðóæíîñòü ïëå÷à (ÎÏ) è ìûøö ïëå÷à (ÎÌÏ) â ñðåäíåé òðåòè. Èíòåãðàëüíûì ïîêàçàòåëåì, îòðàæàþùèì íóòðèòèâíûé ñòàòóñ ÷åëîâåêà, ñëóæèò èíäåêñ ìàññû òåëà (ÈÌÒ), èëè èíäåêñ Êåòëå (òàáë. 6). Ýòîò ïîêàçàòåëü ðàññ÷èòûâàåòñÿ êàê îòíîøåíèå ìàññû òåëà (â êã) ê ðîñòó (ì), âîçâåäåííîìó â êâàäðàò. Èñïîëüçîâàíèå ïðèâåäåííûõ ïîêàçàòåëåé äàåò îáùåå ïðåäñòàâëåíèå î íàðóøåíèè ñîîòíîøåíèé ìåæäó ìàññîé òåëà è ðîñòîì êîíêðåòíîãî ÷åëîâåêà. Ïîñêîëüêó óêàçàííîå íàðóøåíèå ïðîèñõîäèò ãëàâíûì îáðàçîì çà ñ÷åò íàêîïëåíèÿ â îðãàíèçìå æèðîâîé òêàíè, èñïîëüçîâàíèå èíäåêñà Êåòëå âïîëíå ïðèãîäíî äëÿ ñóæäåíèÿ î âûðàæåííîñòè îæèðåíèÿ. Ïðè ýòîì ñëåäóåò ó÷åñòü, ÷òî, ñîãëàñíî ìíåíèþ Êîìèòåòà ýêñïåðòîâ ÂÎÇ, èíäåêñ Êåòëå íå ïîäõîäèò äëÿ îöåíêè ìàññû òåëà ëþäåé ñ ðàçâèòîé ìóñêóëàòóðîé, ëèö ìîëîæå 20 ëåò èëè ñòàðøå 65 ëåò, áåðåìåííûõ è êîðìÿùèõ æåíùèí. Îðèåíòàöèÿ òîëüêî íà ìàññî-ðîñòîâûå ïîêàçàòåëè ìîæåò äàòü íåâåðíîå ïðåäñòàâëåíèå î êîëè÷åñòâå æèðà â ñëó÷àå àòðîôèè ñêåëåòíîé ìóñêóëàòóðû (â ñâÿçè ñ âîçðàñòîì èëè ãèïîäèíàìèåé), íàðóøåíèé âîäíî-ýëåêòðîëèòíîãî áàëàíñà, êîòîðîå âñåãäà èìååòñÿ ó áîëüíûõ íà äèàëèçå. Ñîãëàñíî Åâðîïåéñêèì ðåêîìåíäàöèÿì ïî ïèòàíèþ ó áîëüíûõ íà äèàëèçå ÈÌÒ äîëæåí áûòü âûøå 23 [33], áîëåå íèçêèé ÈÌÒ ïîâûøàåò ëåòàëüíîñòü [27].  ñâåòå ñêàçàííîãî âïîëíå îïðàâäàííûìè ÿâëÿþòñÿ ïîïûòêè áîëåå òî÷íî îïðåäåëÿòü äîëþ æèðîâîãî êîìïîíåíòà â îáùåé ìàññå òåëà. Äîñòóïíûì è äîñòàòî÷íî îáúåêòèâíûì ìåòîäîì ÿâëÿåòñÿ èçìåðåíèå òîëùèíû 810 ÊÆÑ ðàçëè÷íûõ îáëàñòåé òåëà ñïåöèàëüíûì öèðêóëåì-êàëèïåðîì ñ ðàñ÷åòîì æèðîâîãî êîìïîíåíòà ìàññû òåëà â ïðîöåíòàõ îò îáùåé ìàññû. Âåëè÷èíà æèðîâîé ìàññû òåëà â íîðìå íå ïðåâûøàåò ó ìóæ÷èí 1516%, ó æåíùèí 25%. Äëÿ îðèåíòèðîâî÷íîé îöåíêè æèðîîòëîæåíèÿ â êëèíè÷åñêîé ïðàêòèêå ó áîëüíûõ íà äèàëèçå ìîæíî îãðàíè÷èòüñÿ èçìåðåíèåì 4 êîæíî-æèðîâûõ ñêëàäîê (ïîäëîïàòî÷íîé îáëàñòè, íàä òðèöåïñîì, áèöåïñîì, ïîäâçäîøíûì ãðåáíåì). Ïî ñóììå èçìåðåíèé òîëùèíû ÊÆÑ â 4 òî÷êàõ [20] âû÷èñëÿåòñÿ ïðîöåíò ñîäåðæàíèÿ æèðà. Îêðóæíîñòü ïëå÷à îïðåäåëÿåòñÿ ñàíòèìåòðîâîé ëåíòîé â ñðåäíåé òðåòè ëåâîé ðóêè, ñðåäíèå çíà÷åíèÿ äëÿ ìóæ÷èí 2629 ñì, äëÿ æåíùèí 2528 ñì. Îêðóæíîñòü ìûøö ïëå÷à ðàññ÷èòûâàåòñÿ ïî ôîðìóëå: ÎÌÏ (ñì) = ÎÏ (ñì) 0,314 × ÊÆÑ òðèöåïñà. Õàðàêòåðèñòèêà è îöåíêà àíòðîïîìåòðè÷åñêèõ äàííûõ ïðåäñòàâëåíà â òàáë. 7. Èñïîëüçîâàíèå âûøåïåðå÷èñëåííûõ ïîêàçàòåëåé äàåò âîçìîæíîñòü (äîñòàòî÷íî ïðèáëèçèòåëüíî) îöåíèòü ñîñòîÿíèå ìûøå÷íîé ìàññû è æèðîâûõ äåïî. Óìåíüøåíèå ÊÆÑÒ > 10% îò íîðìû ñâèäåòåëüñòâóåò Îáçîðû è ëåêöèè Òà á ë è ö à 6 Õàðàêòåðèñòèêà íóòðèöèîííîãî ñòàòóñà ïî ÈÌÒ (ÂÎÇ, 1997) Êàòåãîðèÿ Äåôèöèò ìàññû òåëà Íîðìàëüíàÿ ìàññà òåëà Èçáûòî÷íàÿ ìàññà òåëà Îæèðåíèå I ñòåïåíè Îæèðåíèå II ñòåïåíè Îæèðåíèå III ñòåïåíè ÈÌÒ, êã/ì2 <18,5 18,524,5 25,029,9 30,034,9 35,039,9 >40,0 Òà á ë è ö à 7 Àíòðîïîìåòðè÷åñêèå ïîêàçàòåëè è èõ îöåíêà Àíòðîïîìåòðè÷åñêèå ïîêàçàòåëè (ñì) ÎÏ (ñì) ÎÌÏ (ñì) ÊÆÑ òðèöåïñà (ìì) Ïîë Íîðìà Ñòåïåíü íåäîñòàòî÷íîñòè ïèòàíèÿ ëåãêàÿ ñðåäíÿÿ òÿæåëàÿ Ìóæ. 2629 2326 Æåí. 2528 22,525 Ìóæ. 2325,7 20,423 Æåí. 2123,4 18,821 2023 19,522,5 1820,4 16,418,8 <20 <19,5 <18 <16,4 Ìóæ. 9,510,5 8,49,5 Æåí. 1314,5 11,613 7,48,4 10,111,6 <7,4 <10,1 îá ýíåðãåòè÷åñêîé íåäîñòàòî÷íîñòè, óìåíüøåíèå ÎÌÏ > 10% ãîâîðèò î áåëêîâîé íåäîñòàòî÷íîñòè, ñî÷åòàíèå äàííûõ íàðóøåíèé ïîçâîëÿåò äèàãíîñòèðîâàòü áåëêîâî-ýíåðãåòè÷åñêóþ íåäîñòàòî÷íîñòü (ñîñòîÿíèå, ïðè êîòîðîì ïîòðåáíîñòè îðãàíèçìà â áåëêå è ýíåðãèè íå îáåñïå÷èâàþòñÿ ïèòàíèåì). Äëÿ îöåíêè ñîñòàâà òåëà ïðèìåíÿþòñÿ è òàêèå ñëîæíûå è äîðîãîñòîÿùèå èíñòðóìåíòàëüíûå ìåòîäû, êàê êîìïüþòåðíàÿ òîìîãðàôèÿ, ßÌÐ-òîìîãðàôèÿ, ïîäâîäíîå âçâåøèâàíèå, äâóõôîòîííàÿ ðåíòãåíîâñêàÿ àáñîðáöèîìåòðèÿ è äðóãèå, êîòîðûå, ê ñîæàëåíèþ, ìàëîïðèãîäíû äëÿ øèðîêîé êëèíè÷åñêîé ïðàêòèêè. Íàìè äëÿ îïðåäåëåíèÿ ñîñòàâà òåëà â òå÷åíèå ïîñëåäíèõ ëåò èñïîëüçóåòñÿ ìåòîä áèîèìïåäàíñíîãî àíàëèçà (ÁÈÀ). Äëÿ åãî îïðåäåëåíèÿ íàìè áûëî óñîâåðøåíñòâîâàíî óñòðîéñòâî ïî åãî îïðåäåëåíèþ [2]. Ïðåèìóùåñòâà äàííîãî ìåòîäà çàêëþ÷àþòñÿ â òîì, ÷òî îí îáúåêòèâåí, íåèíâàçèâåí, äîñòóïåí, îáëàäàåò âûñîêîé äîñòîâåðíîñòüþ. Ýòè ïðåèìóùåñòâà è îáóñëàâëèâàþò âñå âîçðàñòàþùèé èíòåðåñ êëèíèöèñòîâ.  îñíîâó ìåòîäà ïîëîæåíî èçìåðåíèå ïàðàìåòðîâ ïåðåìåííîãî ýëåêòðè÷åñêîãî òîêà ïðè åãî ïðîõîæäåíèè ÷åðåç òêàíè îðãàíèçìà. Íàèáîëåå äîñòîâåðíûå ðåçóëüòàòû îïðåäåëåíèÿ ñîñòàâà òåëà äîñòèãàþòñÿ ïðè èñïîëüçîâàíèè äâóõ÷àñòîòíîé èìïåäàíñîìåòðèè, êîãäà èçìåðåíèÿ ïðîâîäÿòñÿ ïðè çîíäèðîâàíèè òêàíåé òîêîì íèçêîé (520 êÃö) è âûñîêîé (200500 êÃö) ÷àñòîò, ÷òî ïîçâîëÿåò íàèáîëåå òî÷íî îïðåäåëèòü îáúåìû âíåêëåòî÷íîé (ÂÆ) è êëåòî÷íîé æèäêîñòè (ÊÆ) â èññëåäóåìîì ó÷àñòêå òåëà. Ñóììèðóÿ ïîëó÷åííûå çíà÷åíèÿ, îïðåäåëÿþò îáúåì îáùåé æèäêîñòè (ÎÆ). Áåçæèðîâóþ ìàññó òåëà (ÁÆÌ) ðàññ÷èòûâàþò ïî ôîðìóëå ÁÆÌ = k × ÎÆ. Ïðè ýòîì òî÷íîñòü îïðåäåëåíèÿ ÁÆÌ, â îñíîâíîì, çàâèñèò îò âåëè÷èíû ïîãðåøíîñòè îáúåìà ÎÆ è äîñòîâåðíîñòè çíà÷åíèÿ êîýôôèöèåíòà «k». Ñóùåñòâåííîå ïîâûøåíèå òî÷íîñòè îïðåäåëåíèÿ âåëè÷èíû ÎÆ áûëî äîñòèãíóòî íàìè çà ñ÷åò ìåòîäè÷åñêîãî ñîâåðøåíñòâîâàíèÿ èçìåðåíèÿ îáúå- Ò. 10, ¹ 34 2008 · Íåôðîëîãèÿ è äèàëèç 203 Îáçîðû è ëåêöèè ìîâ ÊÆ â ñåãìåíòàõ òåëà ïóòåì èñïîëüçîâàíèÿ âåëè÷èíû åìêîñòíîé ñîñòàâëÿþùåé èìïåäàíñà òêàíåé [3], à òàêæå çà ñ÷åò îïðåäåëåíèÿ îáúåìà æèäêîñòè íèæíèõ êîíå÷íîñòåé â âèäå îòäåëüíûõ èçìåðåíèé îáúåìîâ â áåäðàõ è ãîëåíÿõ [1]. Åñëè áîëüíîé íàõîäèòñÿ â ñîñòîÿíèè ãèïåð- èëè ãèïîãèäðàòàöèè, êîãäà èçìåðåííûå çíà÷åíèÿ ÎÆ îòëè÷àþòñÿ îò íîðìû íà âåëè÷èíó Δ, òî äàííîå îòêëîíåíèå ñóùåñòâåííî âëèÿåò íà òî÷íîñòü îïðåäåëåíèÿ âåëè÷èíû ÁÆÌ. Íàìè áûëà ïðåäëîæåíà íîâàÿ ôîðìóëà îïðåäåëåíèÿ ÁÆÌ: ÁÆÌ = k × ÎÆ ± Δ. ÆÌ îïðåäåëÿåòñÿ ïî ôîðìóëå: ÆÌ = Ð ÁÆÌ, ãäå Ð ìàññà òåëà. Ëàáîðàòîðíûå ìåòîäû Äëÿ îöåíêè íóòðèòèâíîãî ñòàòóñà èñïîëüçóåòñÿ ðÿä ëàáîðàòîðíûõ ïîêàçàòåëåé, îäíàêî êàæäûé èç íèõ, ê ñîæàëåíèþ, èìååò ñóùåñòâåííûå îãðàíè÷åíèÿ â èñïîëüçîâàíèè. Íàèáîëåå ÷àñòî äëÿ îöåíêè ñîñòîÿíèÿ âèñöåðàëüíîãî ïóëà áåëêîâ èñïîëüçóåòñÿ îïðåäåëåíèå àëüáóìèíà. Ìíîãî÷èñëåííûå ðàáîòû ïîêàçàëè ñèëüíóþ êîððåëÿöèþ ìåæäó íèçêèì óðîâíåì àëüáóìèíà â ñûâîðîòêå êðîâè è ëåòàëüíîñòüþ. Îäíàêî àëüáóìèí â áîëüøåé ñòåïåíè ÿâëÿåòñÿ ìàðêåðîì îáùåãî ñîñòîÿíèÿ çäîðîâüÿ, ÷åì ïðîñòî íóòðèòèâíîãî ñòàòóñà. Àëüáóìèí ñîäåðæèòñÿ ïðåèìóùåñòâåííî âî âíåêëåòî÷íîì ïðîñòðàíñòâå, ñèíòåçèðóåòñÿ ïå÷åíüþ è ñåêðåòèðóåòñÿ â êðîâîòîê, ïåðèîä ïîëóæèçíè åãî îêîëî 20 äíåé. Äëèííûé ïåðèîä öèðêóëÿöèè àëüáóìèíà íå ïîçâîëÿåò èñïîëüçîâàòü åãî êàê ðàííèé ìàðêåð íóòðèöèîííûõ íàðóøåíèé. Íåàäåêâàòíîå ïîòðåáëåíèå áåëêà ïðèâîäèò ê ñíèæåíèþ ñèíòåçà àëüáóìèíà è ïîâûøåííîìó êàòàáîëèçìó. Íî íå òîëüêî íåàäåêâàòíîå óìåíüøåíèå áåëêà â ðàöèîíå ìîæåò ïðèâîäèòü ê ãèïîàëüáóìèíåìèè, èìåþò çíà÷åíèå íàëè÷èå çàáîëåâàíèé ïå÷åíè, âîñïàëåíèÿ, íàðóøåíèÿ âîäíîãî áàëàíñà. Ïðè âîñïàëèòåëüíûõ ïðîöåññàõ ìîæåò óâåëè÷èâàòüñÿ òðàíñêàïèëëÿðíàÿ ïîòåðÿ áåëêà. Èçâåñòíà çíà÷èòåëüíàÿ ïîòåðÿ àëüáóìèíà ïðè äèàëèçíûõ ïåðèòîíèòàõ ó áîëüíûõ íà ïåðèòîíåàëüíîì äèàëèçå. Ðåêîìåíäàöèè ïî íîðìàëüíîìó óðîâíþ àëüáóìèíà ó áîëüíûõ ñ ÕÏÍ ìåíÿþòñÿ áûñòðî: åñëè â 2006 ã. Åâðîïåéñêèì îáùåñòâîì ïî ïèòàíèþ áûëî ðåêîìåíäîâàíî ïîääåðæèâàòü êîíöåíòðàöèþ àëüáóìèíà âûøå 35 ã/ë [5], òî óæå â 2007 ã. 40 ã/ë [27]. Áîëåå ÷óâñòâèòåëüíûì ìàðêåðîì íóòðèòèâíîãî ñòàòóñà ïàöèåíòà ñëóæèò óðîâåíü ñûâîðîòî÷íîãî ïðåàëüáóìèíà. Ýòî îáóñëîâëåíî áîëåå êîðîòêèì ïåðèîäîì ïîëóæèçíè (îò 23 äíåé); ìåíüøèì íàðóøåíèåì ñèíòåçà ïðè çàáîëåâàíèÿõ ïå÷åíè; îòñóòñòâèåì âëèÿíèÿ ãèäðàòàöèîííîãî ñòàòóñà ïàöèåíòà íà åãî êîíöåíòðàöèþ. Ëèìèòèðóåò ïðèìåíåíèå âîçìîæíîñòü ïîâûøåíèÿ óðîâíÿ ïðåàëüáóìèíà ïðè àëêîãîëüíîé èíòîêñèêàöèè, òåðàïèè ïðåäíèçîëîíîì è ïðè ÕÏÍ. Ðåêîìåíäîâàííûé óðîâåíü ïðåàëüáóìèíà: 300 ìã/ë è âûøå [27]. Õîðîøèì áèîõèìè÷åñêèì ìàðêåðîì ñîñòîÿíèÿ íóòðèòèâíîãî ñòàòóñà ÿâëÿåòñÿ ñîäåðæàíèå îáùåãî õîëåñòåðèíà: óðîâåíü åãî íå äîëæåí îïóñêàòüñÿ íèæå íîðìàëüíûõ çíà÷åíèé äëÿ äàííîé ëàáîðàòîðèè. Ñëåäóþùèì áåëêîì, îòðàæàþùèì ñîñòîÿíèå íóòðèòèâíîãî ñòàòóñà, ÿâëÿåòñÿ òðàíñôåððèí. Ïåðèîä ïîëóæèç- 204 Íåôðîëîãèÿ è äèàëèç · Ò. 10, ¹ 34 2008 Å.Â. Øóòîâ íè åãî ñîñòàâëÿåò 810 ñóòîê. Îäíàêî åãî óðîâåíü ó áîëüíûõ ñ ÕÏÍ íå íàñòîëüêî èíôîðìàòèâåí, òàê êàê êîíöåíòðàöèÿ òðàíñôåððèíà ïîâûøàåòñÿ â óñëîâèÿõ äåôèöèòà æåëåçà ó áîëüíûõ ñî ñíèæåííîé ôóíêöèåé ïî÷åê. Äðóãèå áèîõèìè÷åñêèå ìàðêåðû äëÿ îöåíêè âèñöåðàëüíîãî áåëêà ïðèìåíÿþòñÿ çíà÷èòåëüíî ðåæå (òðàíñòèðåòèí, ðåòèíîë-ñâÿçûâàþùèé áåëîê, ÈÔÐ-1 è äð.). Êðåàòèíèí ñûâîðîòêè îòðàæàåò îáùóþ ìûøå÷íóþ ìàññó, è åãî íèçêèé óðîâåíü, íå ñîîòâåòñòâóþùèé ñòåïåíè ïî÷å÷íîé íåäîñòàòî÷íîñòè, ñâèäåòåëüñòâóåò îá èñòîùåíèè ïóëà ñîìàòè÷åñêèõ áåëêîâ. Äëÿ îöåíêè àçîòèñòîãî áàëàíñà è îïðåäåëåíèÿ áåëêîâîãî ìåòàáîëèçìà (àíàáîëèçì èëè êàòàáîëèçì) èñïîëüçóþò ñëåäóþùóþ ôîðìóëó [29]: Àçîòèñòûé áàëàíñ (ã/ñóò) = Ïîòðåáëåííûé áåëîê/ 6,25 (àçîò ìî÷åâèíû + 0,031 × âåñ), ãäå 0,031 × âåñ êîíñòàíòà ïîòåðü àçîòà íå ñ ìî÷îé. Èììóíîëîãè÷åñêèå ìåòîäû Èñïîëüçóÿ çíà÷åíèå àáñîëþòíîãî ÷èñëà ëèìôîöèòîâ, ìîæíî ñóäèòü î ñòåïåíè áåëêîâîé íåäîñòàòî÷íîñòè, âûðàæåííîñòè èììóíîñóïðåññèè. Íîðìàëüíûì ïîêàçàòåëåì ñ÷èòàåòñÿ óðîâåíü ÷èñëà ëèìôîöèòîâ áîëåå 1,8 òûñ., ÷èñëî ëèìôîöèòîâ îò 1,5 äî 1,8 òûñ. ñâèäåòåëüñòâóåò î ëåãêîé ñòåïåíè íåäîñòàòî÷íîñòè ïèòàíèÿ, îò 0,9 äî 1,5 î ñðåäíåé è ìåíåå 0,9 òûñ. î òÿæåëîé. Åùå îäíèì ïîêàçàòåëåì áåëêîâîé íåäîñòàòî÷íîñòè ñëóæèò êîæíàÿ ïðîáà ñ ìèêðîáíûì àãåíòîì. Ðàçìåðû ïàïóëû ìåíåå 5 ìì ÷åðåç 48 ÷ ñâèäåòåëüñòâóþò îá èììóíîëîãè÷åñêîé àíåðãèè. Ñíèæåíèå óðîâíÿ èììóíîãëîáóëèíîâ ìîæåò òàêæå óêàçûâàòü íà íåäîñòàòî÷íîñòü ïèòàíèÿ. Ôóíêöèîíàëüíûå ìåòîäû Ïðåäëîæåíû ðàçëè÷íûå òåñòû äëÿ âûÿñíåíèÿ ôóíêöèîíàëüíûõ ñïîñîáíîñòåé, â îñíîâíîì ìûøå÷íîé òêàíè. Îïðåäåëÿåòñÿ ñèëà ñæàòèÿ êèñòè (äèíàìîìåòðîì), ïðîâîäÿòñÿ ïðîáû ñ ïðèñåäàíèÿìè, âåëîýðãîìåòðèÿ è ò. ä. Äèåòà è îñîáåííîñòè ïèòàíèÿ áîëüíûõ ñ ÕÏÍ Áîëüíûì ñ ïî÷å÷íîé íåäîñòàòî÷íîñòüþ åùå â äîäèàëèçíóþ ñòàäèþ äîëæíà íàçíà÷àòüñÿ äèåòà, íàïðàâëåííàÿ íà êîððåêöèþ ìåòàáîëè÷åñêèõ íàðóøåíèé, ñîïðîâîæäàþùèõ óðåìèþ. Áëàãîïðèÿòíîå âëèÿíèå äèåòû íà áèîõèìè÷åñêèå ïîêàçàòåëè âûðàæàåòñÿ, â ÷àñòíîñòè, â ïîâûøåíèè áèêàðáîíàòà êðîâè, ñíèæåíèè óðîâíÿ ôîñôîðà è ìî÷åâèíû. Ýòî ïîëîæèòåëüíîå âëèÿíèå îáóñëîâëåíî ñî÷åòàíèåì ïðèìåíåíèÿ ìàëîáåëêîâîé äèåòû è äîñòàòî÷íîãî ïîñòóïëåíèÿ â îðãàíèçì çàìåíèìûõ è íåçàìåíèìûõ àìèíîêèñëîò äëÿ ñèíòåçà áåëêà [20, 55, 82, 87]. Èñïîëüçîâàíèå íåêîíòðîëèðóåìîé äåôèöèòíîé äèåòû âåäåò ê ïîòåðå ìûøå÷íîé ìàññû, ðàçâèòèþ àöèäîçà, àêòèâàöèè âîñïàëèòåëüíûõ ôåðìåíòîâ è, êàê ñëåäñòâèå, áåëêîâîìó êàòàáîëèçìó [54]. Íàçíà÷åíèå æå ïðè ýòîì âûñîêîáåëêîâîé äèåòû íå ïðèâîäèò ê ñíèæåíèþ êàòàáîëèçìà è óâåëè÷åíèþ ìûøå÷íîé ìàññû. Áîëåå òîãî, âûñîêîáåëêîâàÿ äèåòà ïðèâîäèò ê íàêîï- Íóòðèòèâíûé ñòàòóñ ó áîëüíûõ ñ õðîíè÷åñêîé ïî÷å÷íîé íåäîñòàòî÷íîñòüþ ëåíèþ íåñåêðåòèðóåìûõ èîíîâ ôîñôîðà, êàëèÿ, ïðîäóêòîâ ìåòàáîëèçìà áåëêîâ ñîáñòâåííûõ óðåìè÷åñêèõ òîêñèíîâ (ôåíîëîâ, âåùåñòâ ñðåäíåé ìîëåêóëÿðíîé ìàññû è ò. ä.) [55]. Ñíèæåíèå ïîòðåáëåíèÿ áåëêà ïðèâîäèò ê ñóïðåññèè ïðîòåèíóðèè [7], óìåíüøåíèþ èíñóëèíîðåçèñòåíòíîñòè, êîððåêöèè ìåòàáîëè÷åñêèõ ðàññòðîéñòâ [87] è ñíèæåíèþ ñêîðîñòè ïðîãðåññèðîâàíèÿ ÕÏÍ [44]. Óìåíüøåíèå ïîòðåáëåíèÿ áåëêà íà 0,2 ã/êã/ñóò óìåíüøàåò ñêîðîñòü ïàäåíèÿ êëóáî÷êîâîé ôèëüòðàöèè (ÊÔ) íà 29% è íà 41% óâåëè÷èâàåò âðåìÿ äî íà÷àëà äèàëèçà (ð < 0,01) [50]. Îáúÿñíåíèå ýòîìó íàõîäÿò â òîì, ÷òî ïðè ìàëîáåëêîâîé äèåòå óìåíüøàåòñÿ ïðîòåèíóðèÿ, êîòîðàÿ ÿâëÿåòñÿ âàæíåéøèì ôàêòîðîì ïðîãðåññèðîâàíèÿ ÕÏÍ [69]. Êðîìå òîãî, äèåòà ñ íèçêèì ñîäåðæàíèåì áåëêà óñèëèâàåò ýôôåêò èÀÏÔ â ñóïðåññèè ïðîòåèíóðèè [28]. Ó÷èòûâàÿ âñå ýòè ïðåèìóùåñòâà, íà ñåãîäíÿøíèé äåíü íåò ñîìíåíèé â öåëåñîîáðàçíîñòè íàçíà÷åíèÿ ìàëîáåëêîâîé äèåòû áîëüíûì â äîäèàëèçíîé ñòàäèè ÕÏÍ. Ðåêîìåíäàöèè ïî ïîòðåáëåíèþ áåëêà áîëüíûìè ñ ÕÏÍ ñì. â òàáë. 8. Ïðè ýòîì 5060% áåëêà â ïèùåâîì ðàöèîíå äîëæíû ñîñòàâëÿòü áåëêè âûñîêîé áèîëîãè÷åñêîé öåííîñòè. Íàçíà÷åíèå ïðåïàðàòîâ íåçàìåíèìûõ àìèíîêèñëîò ïîçâîëÿåò ãàðàíòèðîâàòü èõ ïîñòóïëåíèå â íåîáõîäèìîì êîëè÷åñòâå äëÿ ñèíòåçà áåëêîâ îðãàíèçìà è áåçîïàñíî ïðèìåíÿòü ìàëîáåëêîâóþ äèåòó. Ïðåèìóùåñòâî èìåþò êîìïëåêñû êåòîàíàëîãîâ íåçàìåíèìûõ àìèíîêèñëîò (Êåòîñòåðèë), òàê êàê îíè íå ñîäåðæàò àçîòíóþ ãðóïïó è ïðåâðàùåíèå èõ â îðãàíèçìå â Làìèíîêèñëîòû ïðîèñõîäèò ñ çàõâàòîì àìèíîãðóïï, ðàñùåïëåíèåì ìî÷åâèíû, ñïîñîáñòâóÿ ñíèæåíèþ àçîòåìèè. Íàäî ó÷èòûâàòü, ÷òî áîëüíûìè ñ ÕÏÍ äîëæíà ïîòðåáëÿòüñÿ âûñîêîêàëîðèéíàÿ ïèùà. Ïðè ïîòåðå ìûøå÷íîé ìàññû ìîæåò ïîòðåáëÿòüñÿ äî 0,8 ã áåëêà íà êã ìàññû â ñóòêè [51]. Èñïîëüçîâàíèå òàêîãî äèåòè÷åñêîãî ðåæèìà îáåñïå÷èâàåò íåéòðàëüíûé áåëêîâûé áàëàíñ è ñòàáèëüíîñòü òîùåé ìàññû â òå÷åíèå äëèòåëüíîãî âðåìåíè [8, 56]. M. Walser è S. Hill [87] ó 76 ïàöèåíòîâ ñ ÊÔ < 15 ìë/ìèí â òå÷åíèå ãîäà íà ìàëîáåëêîâîé äèåòå äîáèâàëèñü íåéòðàëüíîãî àçîòèñòîãî áàëàíñà, îòñóòñòâèÿ àöèäîçà è íîðìàëüíîãî óðîâíÿ ôîñôîðà è àëüáóìèíà. Ïîõîæèå ðåçóëüòàòû ïîëó÷åíû è M. Aparicio et al. [8] ó 239 ïàöèåíòîâ ñ ÕÏÍ, ñðîê íàáëþäåíèÿ 29,6 ìåñ. Ïîêàçàíî òàêæå, ÷òî ìàëîáåëêîâàÿ äèåòà íå óõóäøàåò âûæèâàåìîñòè ïîñëå íà÷àëà äèàëèçà [15, 17]. Áîëåå òîãî, âûæèâàåìîñòü ïàöèåíòîâ íå óëó÷øàåòñÿ è ïðè ðàííåì íà÷àëå äèàëèçà [10, 85]. Ðåêîìåíäóåìîå ïîòðåáëåíèå ôîñôîðà, êàëèÿ, íàòðèÿ ïðåäñòàâëåíî â òàáë. 9. Ó áîëüíûõ íà ãåìîäèàëèçå è ÏÄ ââèäó äîïîëíèòåëüíûõ ôàêòîðîâ, ïðèâîäÿùèõ ê ðàçâèòèþ íàðóøåíèé íóòðèòèâíîãî ñòàòóñà (îïèñàíû âûøå), äèåòà èçìåíÿåòñÿ â ïîëüçó âûñîêîáåëêîâîé è ñ áîëüøèì ïîòðåáëåíèåì êàëîðèé. Ðåêîìåíäàöèè ïî ïîòðåáëåíèþ áåëêà è êàëîðèé ïðåäñòàâëåíû â òàáë. 10. Ïî ïîêàçàíèÿì ìîæíî íàçíà÷àòü íåçàìåíèìûå êåòî/àìèíîêèñëîòû äëÿ âîñïîëíåíèÿ èõ äåôèöèòà. Áîëüíûì íà äèàëèçå ðåêîìåíäóþò îãðàíè÷èâàòü æèäêîñòü èç ðàñ÷åòà ïîòðåáëåíèÿ 1000 ìë + îáúåì ìî÷è/ñóò. Îáçîðû è ëåêöèè Òà á ë è ö à 8 Ðåêîìåíäàöèè ïî ïîòðåáëåíèþ áåëêà âçðîñëûìè ïàöèåíòàìè â äîäèàëèçíîé ñòàäèè ÕÏÍ [9] ÑÊÔ = 2570 ìë/ìèí ESPEN 0,550,60 0,550,28 + ÝÀÀ/ÊÀ ÑÊÔ ≤ 25 ìë/ìèí NKF 0,60 èëè 0,75 (ïðè íåàäåêâàòíîñòè ïîòðåáëåíèÿ êàëîðèé) Ïðèìå÷àíèå. Çäåñü è äàëåå: ESPEN Åâðîïåéñêîå îáùåñòâî ïî êëèíè÷åñêîìó ïèòàíèþ è ìåòàáîëèçìó; NKF Íàöèîíàëüíûé ïî÷å÷íûé ôîíä; ÝÀÀ íåçàìåíèìûå àìèíîêèñëîòû; ÊÀ êåòîàíàëîãè. Òà á ë è ö à 9 Ðåêîìåíäàöèè ïî ïîòðåáëåíèþ ôîñôîðà, íàòðèÿ, êàëèÿ ó áîëüíûõ ñ äîäèàëèçíîé ÕÏÍ (ESPEN) Ôîñôîð 6001000 ìã/ñóò1 Êàëèé 15002000 ìã/ñóò2 Íàòðèé 1,82,5 ã/ñóò3 1 Çàâèñèò îò ôèçè÷åñêîé àêòèâíîñòè, òîùåé ìàññû, âîçðàñòà è ò. ä. 2 Èíäèâèäóàëüíûé ïîäáîð. 3 Çàâèñèò îò ñòåïåíè ïî÷å÷íîé íåäîñòàòî÷íîñòè, ÀÄ, ïîòðåáëåíèÿ ýíåðãèè è ò. ä. Òà á ë è ö à 1 0 Ðåêîìåíäàöèè ïî ïîòðåáëåíèþ áåëêà è ýíåðãèè ó âçðîñëûõ ïàöèåíòîâ, ïîëó÷àþùèõ äèàëèç ESPEN NKF Ïîòðåáëåíèå Ïîòðåáëåíèå êàëîðèé áåëêà (ã/êã/ñóò) (êêàë/êã/ñóò)* ãåìîïåðèòîãåìîïåðèòîäèàëèç íåàëüíûé äèàëèç íåàëüíûé äèàëèç äèàëèç 1,21,4 1,21,5 3540 3540 1,2 1,21,3 3540 3540 * Âêëþ÷àÿ ýíåðãèþ, ïîëó÷àåìóþ çà ñ÷åò ãëþêîçû äèàëèçàòà. Ñîãëàñíî ïîñëåäíèì Åâðîïåéñêèì ðåêîìåíäàöèÿì ïî ïèòàíèþ [21] äëÿ äèàëèçíûõ áîëüíûõ ðåêîìåíäóåìîå ñóòî÷íîå ïîòðåáëåíèå âèòàìèíîâ: òèàìèíà ãèäðîõëîðèäà (Â1) 1,11,2 ìã; ðèáîôëàâèíà (Â2) 1,11,3 ìã; ïèðèäîêñèíà (Â6) 10 ìã; àñêîðáèíîâîé êèñëîòû (âèòàìèí Ñ) 7590 ìã; ôîëèåâîé êèñëîòû 1 ìã; âèòàìèíà  12 2,4 ìã; áèîòèíà 30 μã; âèòàìèíà  5 5 ìã; âèòàìèíà À 700900 μã; âèòàìèíà Å 400800 ÌÅ; âèòàìèíà Ê 90120 μã. Çàêëþ÷åíèå  íàñòîÿùåå âðåìÿ óæå ñòàëî î÷åâèäíî, ÷òî ïîääåðæàíèå îïòèìàëüíîãî íóòðèöèîííîãî ñòàòóñà ó áîëüíûõ èãðàåò çà÷àñòóþ îïðåäåëÿþùóþ ðîëü â ðåçóëüòàòàõ ëå÷åíèÿ. È ïðèøëî âðåìÿ èíäèâèäóàëüíî îöåíèâàòü ïîêàçàòåëè íóòðèòèâíîãî ñòàòóñà äëÿ çäîðîâûõ è õðîíè÷åñêè áîëüíûõ ëþäåé. Ýòî îñîáåííî àêòóàëüíî, òàê êàê âåñü ìèð çàõëåñòíóë «ìàññîâûé ïñèõîç» ïîõóäåíèÿ, ÷òî, êàê ïîêàçûâàþò ïîñëåäíèå èññëåäîâàíèÿ, ñïîñîáñòâóåò ïîâûøåíèþ ëåòàëüíîñòè ó áîëüíûõ ñ õðîíè÷åñêèìè çàáîëåâàíèÿìè. Ëþäÿì ñ õðîíè÷åñêèìè çàáîëåâàíèÿìè íåîáõîäèìî îðèåíòèðîâàòüñÿ íà áîëåå âûñîêèå ïîêàçàòåëè ïî ÈÌÒ è äðóãèì ñîñòàâëÿþùèì íóòðèöèîííîãî ñòàòóñà. Íåîáõîäèìî ïðîâîäèòü îïòèìàëüíûé ìîíèòîðèíã ñîñòîÿíèÿ áåëêîâî-ýíåðãå- Ò. 10, ¹ 34 2008 · Íåôðîëîãèÿ è äèàëèç 205 Îáçîðû è ëåêöèè Å.Â. Øóòîâ òè÷åñêîãî ïèòàíèÿ, â ÷àñòíîñòè ó áîëüíûõ ñ õðîíè÷åñêîé ïî÷å÷íîé íåäîñòàòî÷íîñòüþ, ÷òî òðåáóåò ñîâìåñòíîé îöåíêè ìíîæåñòâà ïàðàìåòðîâ, îöåíèâàþùèõ ðàçëè÷íûå àñïåêòû íóòðèöèîííîãî ñòàòóñà. Ëèòåðàòóðà 1. Äóäêî Ì.Þ., Øóòîâ Å.Â., Êàïèòàíîâ Å.Í. Óñòðîéñòâî äëÿ èçìåðåíèÿ ýëåêòðè÷åñêîãî èìïåäàíñà â ÷àñòÿõ òåëà. Ïàòåíò íà èçîáðåòåíèå ¹ 2242165 îò 17.07.2003. 2. Äóäêî Ì.Þ., Øóòîâ Å.Â., Êàïèòàíîâ Å.Í., Åðìîëåíêî Â.Ì. Îïðåäåëåíèå «êîëè÷åñòâåííîé íîðìû» îáúåìîâ æèäêîñòíûõ ñåêòîðîâ îðãàíèçìà ñ ïîìîùüþ ñåãìåíòàðíîé èìïåäàíñîìåòðèè. Ýôôåðåíòíàÿ òåðàïèÿ 2004; 10 (4): 2530. 3. Êàïèòàíîâ Å.Í., ×åðíûøåâà Í.Í., Øóòîâ Å.Â. Ïðàêòè÷åñêàÿ ðåàëèçàöèÿ îöåíêè îáúåìà êëåòî÷íîé æèäêîñòè ìåòîäîì ÏÁÈÀ. Äèàãíîñòèêà è ëå÷åíèå íàðóøåíèé ðåãóëÿöèè ñåðäå÷íî-ñîñóäèñòîé ñèñòåìû, 9-ÿ íàó÷íî-ïðàêòè÷åñêàÿ êîíôåðåíöèÿ. Ì., 2007: 132140. 4. Øóòîâ Å.Â. Ïîñòîÿííûé àìáóëàòîðíûé ïåðèòîíåàëüíûé äèàëèç â ëå÷åíèè òåðìèíàëüíîé óðåìèè. Äèñ. ... äîêò. ìåä. íàóê. Ì., 2000: 237. 5. Abbott K.C., Glanton C.W., Trespalacios F.C. et al. Body mass index, dialysis modality, and survival: analysis of the United States Renal Data System Dialysis Morbidity and Mortality Wave II Study. Kidney Int 2004; 65: 597605. 6. Adequacy of dialysis and nutrition in continuous peritoneal dialysis: Association with clinical outcomes. Canada-USA (CANUSA) Peritoneal Dialysis Study Group. J Am Soc Nephrol 1996; 7: 198207. 7. Aparicio M., Chanvenu P., Combe C. Low protein diets and outcome of renal patients. J Nephrol 2001; 14: 433439. 8. Aparicio M., Chauveau P., de Precigout V., Bouchet J.-L., Lasseur C., Combe C. Nutrition and outcome on renal replacement therapy of patients with chronic renal failure treated by a supplemented very low protein diet. J Am Soc Nephrol 2000; 11: 719727. 9. Ballmer P.E., Mc Nurlan M.A., Hulter H.N. et al. Chronic metabolic acidosis decreases albumin synthesis and induces negative nitrogen balance in humans. J Clin Invest 1995; 95: 3945. 10. Beddhu S., Samore M.H., Roberts M.S., Stoddard G.J., Ramkumar N., Pappas L.M., Cheung A.K. Impact of timing of initiation of dialysis on mortality. J Am Soc Nephrol 2003; 14: 23052312. 11. Blum W.F., Ranke M.B., Kietzmann K., Tonshoff B., Mehls O. Growth hormone resistance and inhibition of somatomedin activity by excess of insulin-like growth factor binding protein in uraemia. Pediatr Nephrol 1991; 5: 539544. 12. Bonneux L., Reusser M. Overweight and mortality risk: no connection between overweight in middle and older age groups and increased mortality. Ned Tijdschr Geneeskd 2007; 15: 27642769. 13. Gansevoort R.T., De Zeeuw D., De Jong P.E. Additive antiproteinuric effect of ACE inhibition and a low-protein diet in human renal disease. Nephrol Dial Transpl 1995; 10: 497504. 14. Caravaca F., Arrobas M., Pizarro J. et al. Uremic symptoms, nutritional status and renal function in pre-dialysis end-stage renal failure patients. Nephrol Dial Transplant 2001; 16: 776782. 15. Cecchin F., Ittoop O., Sinha M.K., Caro J.F. Insulin resistance in uremia: Insulin receptor kinase activity in liver and muscle from chronic uremic rats. Am J Physiol 1988; 254: 394401. 16. Chauveau P., Barthe N., Rigalleau V., Ozenne S., Castaing F., Delclaux C., de Precigout V., Combe C., Aparicio M. Outcome of nutritional status and body composition of uremic patients on a very low protein diet. Am J Kidney Dis 1999; 34: 500507. 17. Cheng L., Tang W., Wang T. Strong association between volume status and nutritional status in peritoneal dialysis patients. Am J Kidney Dis 2005; 45: 891902. 18. Coresh J., Walser M., Hill S. Survival on dialysis among chronic renal failure patients treated with a supplemented low-protein diet before dialysis. J Am Soc Nephrol 1995; 6: 13791385. 19. Degoulet P., Legrain M., Reach I. et al. Mortality risk factors in patients treated by chronic hemodialysis. Report of the Diaphane collaborative study. Nephron 1982; 31: 103110. 20. Detsky A.S., McLaughlin J.R., Baker J.P., Johnston N., Whittaker S., Mendelson R.A., Jeejeebhoy K.N. What is subjective global assessment of nutritional status? J Parenter Enteral Nutr 1987; 11: 813. 21. Durnin J.V., Womersley J. Body fat assessed from total body density and its estimation from skinfold thickness: Measurements on 206 Íåôðîëîãèÿ è äèàëèç · Ò. 10, ¹ 34 2008 481 men and women aged from 16 to 72 years. Br J Nutr 1974; 32: 7797. 22. EBPG guideline on nutrition. Nephrol Dial Transplant 2007; 22 (Suppl. 2): 4587. 23. Enia G., Sicuso C., Alati G., Zoccali C. Subjective global assessment of nutrition in dialysis patients. Nephrol Dial Transplant 1993; 8: 10941098. 24. Feldman A.M., Combes A., Wagner D. et al. The role of tumor necrosis factor in the pathophysiology of heart failure. J Am Coll Cardiol 2000; 35: 537544. 25. Fleischmann E., Teal N., Dudley J., May W., Bower J.D., Salahudeen A.K. Influence of excess weight on mortality and hospital stay in 1346 hemodialysis patients. Kidney Int 1999; 55: 15601567. 26. Foley R.N., Parfrey P.S., Sarnak M.J. Epidemiology of cardiovascular disease in chronic renal disease. J Am Soc Nephrol 1998; 9: 16 23. 27. Fontan M.P., Rodrigues-Carmona A., Cordido F. et al. Hyperleptinemia in uremic patients undergoing conservative management, peritoneal dialysis and hemodialysis: A comparative analysis. Am J Kidney Dis 1999; 34: 824831. 28. Fouque D., Vennegoor M., Piet Ter Wee et al. EBPG Guideline on Nutrition Nephrology Dialysis Transplantation 2007; 22 (2): 4587. 29. Goldstein D.J. Assessment of nutritional status in renal disease. In: Mitch W.E., Klahr S., eds. Handbook of nutrition and the kidney, 3rd ed. Philadelphia, 1998: 4686. 30. Grabowski D.C., Ellis J.E. High body mass index does not predict mortality in older people: analysis of the Longitudinal Study of Aging. J Am Geriatr Soc 2001; 49: 968979. 31. Gutierrez A., Begstrom J., Alvestrand A. Hemodialysis-associated protein catabolism with and without glucose in the dialysis fluid. Kidney Int 1994; 46: 814822. 32. Herbelin A., Urena P., Nguyen A.T. et al. Elevated circulating levels of interleukin-6 in patients with chronic renal failure. Kidney Int 1991; 39: 954960. 33. Horwich T., Hamilton M., Fonarow D. B-type natriuretic peptide levels in obese patients with advanced heart failure. J Am Coll Cardiol 2006; 3: 47 (1): 8590. 34. Horwich T.B., Fonarow G.C., Hamilton M.A., MacLellan W.R., Woo M.A., Tillisch J.H. The relationship between obesity and mortality in patients with heart failure. J Am Coll Cardiol 2001; 38: 789795. 35. Hotamisligil G.S., Peraldi P., Budavari A., Ellis R., White M.F., Spiegelman B.M. IRS-1-mediated inhibition of insulin receptor tyrosine kinase activity in TNFα- and obesity-induced insulin resistance. Science 1996; 271: 665668 [Abstract]. 36. Hylander B., Barkeling B., Rossner S. Eating behavior in continuous ambulatory peritoneal dialysis and hemodialysis patients. Am Kidney Dis 1992; 20: 592597. 37. Ikizler T., Flakoll P., Parker R. et al. Amino acid and albumin losses during hemodialysis. Kidney Int 1994; 46: 830837. 38. James L., Bailey J.L., Bin Zheng et al. Chronic Kidney Disease Causes Defects in Signaling through the Insulin Receptor Substrate/ Phosphatidylinositol 3-Kinase/Akt Pathway: Implications for Muscle Atrophy. J Am Soc Nephrol 2006; 17: 13881394. 39. Jones C., Akbani H., Croft D. et al. The relationship between serum albumin and hydration status in hemodialysis patients. J Ren Nutr 2002; 12: 209212. 40. Kalantar-Zadeh K., Block G., Humphreys M.H. et al. A low, rather than a high, total plasma homocysteine is an indicator of poor outcome in hemodialysis patients. J Am Soc Nephrol 2004; 15: 442453. 41. Kalantar-Zadeh K., Block G., Humphreys M.H. et al. Reverse epidemiology of cardiovascular risk factors in maintenance dialysis patients. Kidney Int 2003; 63: 793808. 42. Kalantar-Zadeh K., Abbot K., Salahudeen K. et al. Survival advantages of obesity in dialysis patients. Am J Clin Nutr 2005; 81 (3): 543554. 43. Kano N., Fiaccadori E., Tesinsky P. et al. ESPEN Guidelines on Enteral Nutrition Adult Renal Failure. Clinical Nutrition 2006; 25: 295310. 44. Klahr S., Levey A.S., Beck G.L. et al. The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal failure. N Engl J Med 1994; 330: 878884. 45. Kopple J.D. Nutritional status as a predictor of morbidity and mortality in maintenance dialysis patients. Asaio J 1997; 43 (3): 246 250. 46. Kopple J., Greene T., Chumlea W. et al. Relationship between nutritional status and the glomerular filtration rate: Results from the MDRD study. Kidney Int 2000; 57: 16881703. Íóòðèòèâíûé ñòàòóñ ó áîëüíûõ ñ õðîíè÷åñêîé ïî÷å÷íîé íåäîñòàòî÷íîñòüþ 47. Kopple J.D., Levey A.S., Green T. et al. Effect of dietary protein restriction of nutritional status in the Modification of Diet in Renal Disease (MDRD) Study. Kidney Int 1997; 52: 778791. 48. Kovesdy C., Anderson J. Reverse epidemiology in patients with chronic kidney disease who are not yet on dialysis. Semin Dial 2007; 20 (6): 566569. 49. Leavey S.F., Strawderman R.L., Jones C.A., Port F.K., Held P.J. Simple nutritional indicators as independent predictors of mortality in hemodialysis patients. Am J Kidney Dis 1998; 31: 9971006. 50. Levey A.S., Adler S., Caggiula A.W., England B.K., Greene T., Hunsicker L.G., Kusek J.W., Rogers N.L., Teschan P.E. MDRD Study Group: Effects of dietary protein restriction on the progression of advanced renal disease in the Modification of Diet in Renal Disease Study. Am J Kidney Dis 1996; 27: 652663. 51. Maroni B.J., Staffeld C., Young V.R., Manatunga A., Tom K. Mechanisms permitting nephrotic patients to achieve nitrogen equilibrium with a protein-restricted diet. J Clin Invest 1997; 99: 24792487. 52. Memoli B., Postiglione L., Cianciaruso B. et al. Role of different dialysis membranes in the release of interleukin-6 soluble receptor in uremic patients. Kidney Int 2000; 58: 417424. 53. Mitch W.E., Goldberg A.L. Mechanisms of muscle wasting. The role of the ubiquitin-proteasome pathway. N Engl J Med 1996; 335: 18971905. 54. Mitch W.E., Price S.R. Transcription factors and muscle cahexia: have we defined a therapeutic target? Lancet 2001; 357: 734735. 55. Mitch W.E., Walser N. Nutritional therapy of the uremic patient. In: The Kidney. Ed. by B.M. Breuner. Philadelphia: W.B. Sanders, 2000: 22982340. 56. Mitch W.E. Requirements for protein, calories, and fat in the predialysis patients. In: Handbook of Nutrition and the Kidney. Ed. by W.E. Mitch, S. Klahr. Philadelphia: Lippincott, Williams and Wilkins, 2002: 144165. 57. Mohamed-Ali V., Goodrick S., Bulmer K. et al. Production of soluble tumor necrosis factor receptors by human subcutaneous adipose tissue in vivo. Am J Physiol 1999; 277: 971975. 58. Moxley M., Bell N., Wagle S. et al. Parathyroid hormone stimulation of glucose and urea production in isolated liver cells. Am J Physiol 1974; 227: 10581061. 59. Neyra R., Chen K., Sun M. et al. Increased resting energy expenditure in patients with end-stage renal disease. J Parenter Enteral Nutr 2003; 27: 3642. 60. Niebauer J., Volk H., Kemp M. et al. Endotoxin and immune activation in chronic heart failure a prospective cohort study. Lancet 1999; 353: 18381842. 61. Nishizawa Y., Shoji T., Ishimura E. et al. Paradox of risk factors for cardiovascular mortality in uremia: is a higher cholesterol level better for atherosclerosis in uremia? Am J Kidney Dis 2001; 38: 47. 62. Odamaki M., Furuya R., Yoneyama T. et al. Association of the serum leptin concentration with weight loss in chronic hemodialysis patients. Am J Kidney Dis 1999; 33: 361368. 63. Patel V.B., Topol E.J. The pathogenesis and spectrum of acute coronary syndromes: from plaque formation to thrombosis. Cleve Clin J Med 1999; 66: 561571. 64. Pollock C., Ibels L., Zhu F. et al. Protein intake in renal disease. J Am Soc Nephrol 1997; 8: 777783. 65. Powell D.R., Rosenfeld R.G., Hintz R.L. Effects of growth hormone therapy and malnutrition on the growth of rats with renal failure. Pediatr Nephrol 1988; 2: 425430. 66. Rauchhaus M., Coats A.J., Anker S.D. The endotoxin-lipoprotein hypothesis. Lancet 2000; 356: 930933. 67. Rauchhaus M., Koloczek V., Volk H. et al. Inflammatory cytokines and the possible immunological role for lipoproteins in chronic heart failure. Int J Cardiol 2000; 76: 125133. 68. Reaich D., Channon S., Scrimgeour C. et al. Correction of acidosis in humans with CRF decreases protein degradation and amino acid oxidation. Am J Physiol 1993; 265: 230235. 69. Remuzzi G., Bertani T. Pathophysiology of progressive nephropathies. N Engl J Med 1998; 339: 14481456. Îáçîðû è ëåêöèè 70. Romero-Corral A., Montori V., Somers U. et al. Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic review of cohort studies. Lancet 2006; 368 (9536): 666678. 71. Ross R. Atherosclerosis an inflammatory disease. N Engl J Med 1999; 340: 115126. 72. Rui L., Aguirre V., Kim J.K. et al. Insulin/IGF-1 and TNFα stimulate phosphorylation of IRS-1 at inhibitory Ser307 via distinct pathways. J Clin Invest 2001; 107: 181189. 73. Salahudeen A.K., Fleischmann E.H., Bower J.D. et al. Underweight rather than overweight is associated with higher prevalence of hypertension: BP vs. BMI in hemodialysis population. Nephrol Dial Transplant 2004; 19: 427432. 74. Salahudeen A.K. Obesity and survival on dialysis. Am J Kidney Dis 2003; 41: 925932. 75. Schrier R.W., Abraham W.T. Hormones and hemodynamics in heart failure. N Engl J Med 1999; 341: 577585. 76. Sherwin R.S., Bastl C., Finkelstein F. et al. Influence of uremia and hemodialysis on the turnover and metabolic effects of glucagons. J Clin Invest 1976; 57: 722731. 77. Snyder J.J., Foley R.N., Gilbertson D.T. et al. Body size and outcomes on peritoneal dialysis in the United States. Kidney Int 2003; 64: 18381844. 78. Stenvinkel P., Heimburger O., Lindholm B. et al. Are there two types of malnutritient in chronic renal failure? Evidence for relationships between malnutrition, inflammation and atherosclerosis (MIAsindrome). Nephrol Dial Transpl 2000; 15: 953960. 79. Stenvinkel P., Heimburger O., Lonnqvist F. Serum leptin concentrations correlate to plasma insulin concentrations independent of body fat content in chronic renal failure Nephrol Dial Transplant 1997; 12: 13211325. 80. Stenvinkel P., Heimburger O., Paultre F. et al. Strong association between malnutrition, inflammation, and atherosclerosis in chronic renal failure. Kidney Int 1999; 55: 18991911. 81. Stenvinkel P., Lindholm B., Lonqvist F. et al. Increases in serum leptin levels during peritoneal dialysis are associated with inflammation and decrease in lean body mass. J Am Soc Nephrol 2000; 11: 13031309. 82. Sugimoto T., Kikkawa R., Haneda M., Shigeta Y. Effect of dietary protein restriction on proteinuria in non-insulin-dependent diabetic patients with nephropathy. J Nutr Sci Vitaminol 1996; 37: 8792. 83. Tielemans C., Husson C., Schurmans T. et al. Effects of ultrapure and non-sterile dialysate on the inflammatory response during in vitro hemodialysis. Kidney Int 1996; 49: 236243. 84. Toigo G., Aparacio M., Attman P. et al. Espen consensus on nutritional treatment of patients with renal insufficiency. Clin Nutr 2000; 19: 197207. 85. Traynor J.P., Simpson K., Geddes C.C., Deighan C.J., Fox J.G. Early initiation of dialysis fails to prolong survival in patients with endstage renal failure. J Am Soc Nephrol 2002; 13: 21252132. 86. United States Renal Data System. U.S. Department of Public Health and Human Services, Public Health Service Bethesda, MD: National Institutes of Health. 1998. 87. Walser M., Hill S. Ñan renal replacement be differed by a supplemented very-low protein diet? J Am Soc Nephrol 1999; 10: 110 116. 88. Walser M., Mitch W.E., Maroni B.J., Kopple J.D. Should protein be restricted in predialysis patients? Kidney Int 1999; 55: 771777. 89. Wang X., Hu Z., Hu J. et al. Insulin Resistance Accelerates Muscle Protein Degradation: Activation of the Ubiquitin-Proteasome Pathway by Defects in Muscle Cell Signaling. Endocrinology 2006; 147; 9: 41604168. 90. Weber M.A., Neutel J.M., Smith D.H. Contrasting clinical properties and exercise responses in obese and lean hypertensive patients. J Am Coll Card 2001; 37: 169174. 91. Zager P.G., Nikolic J., Brown R.H. et al. «U» curve association of blood pressure and mortality in hemodialysis patients. Medical Directors of Dialysis Clinic, Inc. Kidney Int 1998; 54: 561569. Ò. 10, ¹ 34 2008 · Íåôðîëîãèÿ è äèàëèç 207
![ISSN 1561-6274. Нефрология. 2009. Том 13. №3. © Ì.Ì.Âîëêîâ, 2009 ÓÄÊ 616.61-036.12-008.9]:546.41+546.18](http://s1.studylib.ru/store/data/002088276_1-4bc2ed86dc4c87a6d852f5029de422b0-300x300.png)
