Нутритивный статус у больных с хронической почечной

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 – 10–70% [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]. Â 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 3–4 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 25–29,9 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 3–4 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 30–50% 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 2–3 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 3–4 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 3–15 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 2–3 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 2–3 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 1,5–2 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 (1–3,5 ã), âèòàìèíîâ è áåëêà (5–15 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 3–4 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 (1–2 áàëëà); 5–10% – ñðåäíÿÿ (3–5 áàëëîâ);
äî 5% – îòñóòñòâóåò èëè íåçíà÷èòåëüíàÿ (6–7 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 8–10 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 15–16%, 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 26–29 ñì, äëÿ æåíùèí 25–28 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
18,5–24,5
25,0–29,9
30,0–34,9
35,0–39,9
>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. 26–29
23–26
Æåí. 25–28 22,5–25
Ìóæ. 23–25,7 20,4–23
Æåí. 21–23,4 18,8–21
20–23
19,5–22,5
18–20,4
16,4–18,8
<20
<19,5
<18
<16,4
Ìóæ. 9,5–10,5 8,4–9,5
Æåí. 13–14,5 11,6–13
7,4–8,4
10,1–11,6
<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. Â 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 (5–20 êÃö) è âûñîêîé (200–500 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 3–4 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 2–3 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 3–4 2008
Å.Â. Øóòîâ
íè åãî ñîñòàâëÿåò 8–10 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 áåëêî⠖ 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 50–60% 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 = 25–70 ìë/ìèí
ESPEN
0,55–0,60
0,55–0,28 +
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 600–1000 ìã/ñóò1
Êàëèé 1500–2000 ìã/ñóò2
Íàòðèé 1,8–2,5 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
1,2–1,4
1,2–1,5
35–40
35–40
1,2
1,2–1,3
35–40
35–40
* 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) – 1,1–1,2 ìã; ðèáîôëàâèíà (Â2) –
1,1–1,3 ìã; ïèðèäîêñèíà (Â6) – 10 ìã; àñêîðáèíîâîé
êèñëîòû (âèòàìèí Ñ) – 75–90 ìã; ôîëèåâîé êèñëîòû –
1 ìã; âèòàìèíà  12 – 2,4 ìã; áèîòèíà – 30 μã; âèòàìèíà  5 – 5 ìã; âèòàìèíà À – 700–900 μã; âèòàìèíà Å –
400–800 ÌÅ; âèòàìèíà Ê – 90–120 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 3–4 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.
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