Уремическая миопатия у больных хронической болезнью почек | in Library

Уремическая миопатия у больных хронической болезнью почек

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Даминов, Б., Хайдарова, Ф., Алиева, А., Расулев, `Ё, & Холмухамедов, Ж. (2023). Уремическая миопатия у больных хронической болезнью почек. in Library, 22(1), 131–138. извлечено от https://inlibrary.uz/index.php/archive/article/view/26340
Б Даминов, Ташкентский Педиатрический Медицинский Институт
Ташкентский  педиатрический  медицинский  институт,  Ташкент,  Узбекистан 1 ,  Республиканский  специализированный  научно-практический  медицинский  центр  нефрологии  и  трансплантации  почки, Ташкент, Узбекистан
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Аннотация

В данной статье рассмотрены вопросы уремической миопатии у больных с хронической болезню почек.


background image

131

УДК 616,1:616.61–05

SURUNKALI BUYRAK KASALLIGI BO‘LGAN BEMORLARDA UREMIK MIYOPATIYA

DAMINOV B.T.

1,2

,

XAYDAROVA F.A.

3

, ALIYEVA A.V.

3

, RASULEV Y.E.

1

, HOLMUHAMEDOV J.A.

1

Toshkent pediatriya tibbiyot instituti, Toshkent, O‘zbekiston

1

, Respublika ixtisoslashtirilgan nefrologiya va buyrak

transplantatsiyasi ilmiy-amaliy tibbiyot markazi, Toshkent, O‘zbekiston

2

Akademik Yo. Kh. Turakulov nomidagi 

Respublika ixtisoslashtirilgan endokrinologiya ilmiy-amaliy tibbiyot markazi, Toshkent, O‘zbekiston

3

XULOSA

SURUNKALI BUYRAK KASALLIGI BO‘LGAN BEMORLARDA UREMIK MIYOPATIYA

Daminov B.T.

1,2

,

Xaydarova F.A.

3

,

Aliyeva A.V.

3

,

Rasulev Y.E.

1

,

 Holmuhamedov J.A.

1

Toshkent  pediatriya  tibbiyot  instituti,  Toshkent,  O‘zbekiston

1

,  Respublika  ixtisoslashtirilgan 

nefrologiya  va  buyrak  transplantatsiyasi  ilmiy-amaliy  tibbiyot  markazi,  Toshkent,  O‘zbekiston

2

, 

Akademik  Yo.  Kh.  Turakulov  nomidagi  Respublika  ixtisoslashtirilgan  endokrinologiya  ilmiy-amaliy 

tibbiyot markazi, Toshkent, O‘zbekiston

3

Ushbu maqolada surunkali buyrak kasalligi bo‘lgan bemorlarda uremik miopatiya muammolari muhokama

qilinadi.

Kalit so‘zlar:

surunkali buyrak kasalligi, gemodializ.

SUMMARY

UREMIC MYOPATHY IN PATIENTS WITH CHRONIC KIDNEY DISEASE

Daminov B.T.

1,2

,

Khaidarova F.A.

3

,

Aliyeva A.V.

3

,

Rasulev Y.E.

1

,

Kholmukhamedov J.A.

2

Tashkent  pediatric  medical  institute,  Tashkent,  Uzbekistan

1

,

Republican  specialized  scientific-

practical medical center of nephrology and kidney transplantation, Tashkent, Uzbekistan

2

, Republican 

specialized scientific and practical medical center of endocrinology named after academician Ya. Kh. 

Turakulov, Tashkent, Uzbekistan

3

This article discusses the issues of uremic myopathy in patients with chronic kidney disease.

Key words:

chronic kidney disease, hemodialysis.

РЕЗЮМЕ

УРЕМИЧЕСКАЯ МИОПАТИЯ У БОЛЬНЫХ ХРОНИЧЕСКОЙ БОЛЕЗНЬЮ ПОЧЕК
Даминов Б.Т.

1,2

,

Хайдарова Ф.А.

3

,

Алиева А.В.

3

,

Расулев Ё.Э.

1

,

Холмухамедов Ж.А.

2

Ташкентский  педиатрический  медицинский  институт,  Ташкент,  Узбекистан

1

,  Республиканский 

специализированный  научно-практический  медицинский  центр  нефрологии  и  трансплантации 

почки, Ташкент, Узбекистан

2

, Республиканский специализированный научно-практический меди-

цинский центр эндокринологии имени Академика Ё.Х. Туракулова, Ташкент, Узбекистан

3

В данной статье рассмотрены вопросы уремической миопатии у больных с хронической болезню почек.

Ключевые слова:

хроническая болезнь почек, гемодиализ.

S

urunkali buyrak kasalligi (SBK) bilan og’rigan

bemorlarda, ayniqsa gemodializda bo‘lganlarda,

ko‘pincha mushaklarning sezilarli zaifligi va chidamliligi

yo‘q. Bu ko‘pincha harakatsiz turmush tarziga olib ke

-

ladi, bu kasallikning kuchayishiga olib keladi va gemo

-

dializ bilan og’rigan bemorlarda kasallanish va o‘limni

oshiradi.

Jismoniy mashqlar kasallikning kuchayishiga ta‘sir

-

ini, kamaytirish ta‘sirini berishi mumkin, yoki yumshati

-

shi va omon qolishni yaxshilashi mumkin.

Ushbu mavzuda uremik miyopatiyaning pato

-

fiziologiyasi va uning SBK va gemodializ bilan og’rig

-

an bemorlarning harakatsiz turmush tarziga ta‘siri

ko‘rib chiqiladi. Jismoniy mashqlarning foydali ta‘siri

muhokama qilinadi va gemodializ bo‘lmagan SBK va

gemodializ bemorlari uchun tavsiyalar beriladi.

Uremik miyopatiya SBK bilan og’rigan bemor

-

larda, ayniqsa gemodiyalizda bo‘lganlarda, jismoniy

funksiyaning aniq pasayishini hisobga olgan holda

keng tarqalgan hisoblanadi [1, 2]. Biroq, uremiya bi

-

lan bevosita bog’liq bo‘lgan o‘ziga xos patofiziologik

jarayonning tarqalishi yaxshi aniqlanmagan, chunki

simptomlar kichik va sekin rivojlanib boradi va aniq di

-

agnostika mezonlari yo‘q [3]. 330 gemodializ bemorini

o‘z ichiga olgan bir tadqiqotda sarkopeniya (funksiya/

harakatchanlikning pasayishi bilan mushak massasi

-

ning kamayishi) 20 foizda, faqat mushak massasining

kamayishi 24 foizda va mushak kuchining pasayishi 15

foizda kuzatilgan [4].

Patofiziologiya. 

SBK bilan kasallangan bemorlar

-

da sarkopeniya yoki atrofiya va zaiflikni keltirib chiqa

-

radigan omillarga uremiya sabab bo‘lgan yallig’lan

-

ish va aktiv shakldagi kislorodning to‘planishi kiradi,

bu esa mitoxondriyal ajralish va mushaklarni tiklash

mexanizmlarining yetishmasligiga olib keladi [5–7].

Harakatsiz turmush tarziga SBK uchun xos bo‘lma

-


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132

gan, shuningdek, qandli diabet, noto‘g’ri ovqatlanish va

periferik qon tomir kasalliklari kabi komorbid kasalliklar

kabi mushaklarning buzilishida kuchayishida muhim

rol o‘ynaydi. Eritropoetin, D vitamini va androgen ye

-

tishmovchiligi mushaklar kuchsizligiga sabab boladi.

Tadqiqotlar shuni ko‘rsatdiki, SBKda mitoxondriyal

samaradorlik pasayadi, bu kislorod iste’moli birligiga

adenozin trifosfat (ATP) ishlab chiqarishning pasayishi

bilan tavsiflanadi (ya‘ni, mitoxondriyal ajralish) [8, 9].

Mitoxondriyal ajralish jismoniy mashqlar bardoshliligi

va chidamliligining funksional pasayishidan oldin sodir

bo‘lishi mumkin [10]. Mitoxondriyal ajralishning dast

-

labki sababi noma‘lum, ammo ko‘ptokchalar filtratsiya

tezligi (KFT) pasayishi tufayli oksidlovchi stressning

kuchayishi bilan bog’liq bo‘lishi mumkin [11].

Harakatsiz  turmush  tarzi. 

Harakatsiz turmush

tarzi SBKda miyopatiyaga kuchayishiga asosiy hissa

qo‘shadi. Harakatsiz turmush tarzi – bu harakatsizlik

natijasida yuzaga keladigan mushak massasi (sarko

-

peniya), kuch va quvvatni yo‘qotishdir [12]. Manfredi

-

ni F va hammualiflar uremik miyopatiyada harakatsiz

turmush tarzining roli miyopatiya belgisi sifatida dam

olish paytida mushaklarning kislorod iste’moli (rmVO

2

)

ishlatilgan tadqiqotda ko‘rsatildi [13]. «rmVO

2

» ko‘rsat

-

kichi SBK oxirgi bosqichda bilan og’rigan bemorlar

-

da sog’lom odamlar bilan solishtirganda ikki baravar

yuqori edi.

SBK bilan og’rigan bemorlar harakatsiz turmush

tarziga – juda zaifdir. SBK bilan og’rigan bemorlar,

sog’lom odamlarga qaraganda kamroq faol bo‘lishadi

[14–16]. Faoliyat darajasining pasayishi sabablari

to‘liq tushunilmagan, ammo mushaklarning erta char

-

choqlari (ehtimol, mitoxondriyal ajralish tufayli yuzaga

kelgan), kamqonlik, ko‘plab kasalliklar va kasalxonaga

yotqizish rol o‘ynashi mumkin.

Harakatsiz turmush tarzi qayta tiklanadi. Yuqorida

keltirilgan tadqiqotda olti oylik jismoniy mashqlar SBK

bilan og’rigan bemorlarning rmVO

2

ning pasayishiga

olib keldi; 39 foizi esa normal rmVO

2

ga erishishdi [13].

Ko‘pgina tadqiqotlar shuni ko‘rsatdiki, jismoniy

mashqlar SBK bilan og’rigan bemorlarning mushaklari

faoliyatini va jismoniy faoliyatini yaxshilaydi [17–19].

Eritropoetin yetishmovchiligi. 

Eritropoetin yetish

-

movchiligi miopatiyaga o‘z hissini qo‘shishi mumkin,

ammo bu aniq emas, chunki bu kamqonlik mushaklar

-

ga kislorod yetkazib berishning pasayishiga olib keladi

va/yoki harakatsizlik va harakatsiz turmush tarziga his

-

sisini qo‘shadi yoki eritropoetin mushaklarga bevosita

ta‘sir qiladi.

Kamqonlikni eritropoetin bilan davolash SBK bilan

og’rigan bemorlarda chidamlilik va kuchini yaxshilaydi

[20]. Dastlabki tadqiqotda, eritropoetin bilan kamqonli

-

kni 11 g/dL maqsadli gemoglobin darajasigacha davo

-

lash, 11 bemorda uch oy ichida qo‘l va oyoq mushak

-

larining kuchini 10–30 foizga oshirishga olib keldi,

ammo bu yaxshilanish hali ham davom etmoqda. Be

-

morlarni sog’lom nazorat guruhiga qaraganda ancha

kuchliroq qoldirdi [21].

Eritropoetin bilan davolash bilan mushaklarn

-

ing tuzilishi yaxshilanadi. Bir tadqiqotda kamqonlikni

davolashdan oldin va keyin o‘tkazilgan mushak biop

-

siyalari mushak tolalari diametrining yaxshilanishini

va kamqonlik qisman davolanganidan so‘ng, mushak

tolalarini anormalliklarning kamayishini ko‘rsatdi [22].

Ushbu o‘zgarishlar mushaklarning kuchi va ishlash

-

ining oshishiga olib keladi va, ehtimolki, mushaklarga

kislorod yetkazib berishning ko‘payishi natijasidir.

Eritropoetin mushaklarga to‘g’ridan to‘g’ri ta‘sir qil

-

ishi mumkinligi (ya‘ni kamqonlik bilan bog’liq bo‘lma

-

gan), uremiya bo‘lmagan bemorlarda (endogen eritro

-

poetin darajasining pasayishi kutilmaydigan) qon quy

-

ish bilan kamqonlikni davolash mumkin emasligi bilan

izohlanadi [23].

ANDROGEN YETISHMOVCHILIGI

Erkak va ayol SBK bilan og’rigan bemorlarda an

-

drogen ishlab chiqarish kamayadi.

Androgen yetishmovchiligi – mushaklarning bu

-

zilishiga yordam beradi. Rekombinant eritropoetin

mavjud bo‘lgunga qadar, ba‘zi gemodializ bemorlari

-

da kamqonlikni davolash uchun androgen terapiyasi

qo‘llanilgan [24, 25] va bir tadqiqotda androgen, nan

-

drolon dekanoat mushak massasini oshirishi qayd

etilgan [25, 26]. Keyinchalik bu agent tana tarkibi va

mushaklar kuchini yaxshilashi ko‘rsatildi [27, 28]. Bir

tadqiqotda 79 bemor tasodifiy ravishda 2x2 faktorial

tarzda anabolik steroidlarni qabul qilish va qarshilik

mashqlarini o‘qitish uchun tayinlangan [28]. Nandrolon

dekanoat tana massasini va mushaklar hajmini oshi

-

rardi.

D  vitamini  tanqisligi. 

d vitamini yetishmovchiligi

turli sabablarga ko‘ra miyopatiyalar bilan bog’liq, shu

jumladan statinlar va D vitaminiga bog’liq raxit [29–

31]. Bir nechta hisobotlarda D vitaminining tegishli

dozalari bilan qo‘shilishi mushaklarning faoliyatini

yaxshilagan [29–31].

Ikkilamchi  giperparatireoidizm. 

Birlamchi [32–

35] va ikkilamchi giperparatireoz [36, 37] bo‘lgan

bemorlarda miyopatiya haqida xabar berilgan.

Birlamchi giperparatireoz bilan bog’liq bo‘lgan

miopatiya paratireoid gormonining kamayishi bilan

orqaga qaytishi ko‘rsatilgan [33, 35]. Biroq, ikkilamchi

giperparatireoz haqida chop etilgan hisobotlarda

paratireoid

gormonining

ta‘sirini

D

vitamini

yetishmovchiligi va uremiya ta‘siridan ajratish qiyin

[36, 37].

Karnitin  tanqisligi. 

Ba‘zi tadqiqotlar shuni

ko‘rsatdiki, L-karnitin qo‘shimchasi mushaklar kuchini

yaxshilaydi, ammo chidamlilikni oshirmaydi [38, 39].

Biroq, mushaklarning metabolizmi va funksiyasi

magnit-rezonans yoki yaqin infraqizil spektroskopiya

bilan baholanganda, gemodializni olgan bemorlarda

16 hafta davomida L-karnitin qo‘shilishi hech qanday

ta‘sir ko‘rsatmadi [40].

Gemodializga  kirish. 

Gemodializga

kirish

mushaklar faoliyatiga mahalliy ta‘sir ko‘rsatishi

mumkin. Bilakda arterio – venoz fistulaga kirish

ta‘sirlangan qo‘lning katta va nozik motorli

ko‘nikmalariga ta‘sir qilishi mumkin [41]. Gemodializga

kirish yoki peritoneal dializ kateteri kirish yoki

kateterga zarar yetkazishdan qo‘rqib, bemorning

faolligini kamaytirishi mumkin. Garchi ko‘pincha

kirish imkoniyati bo‘lgan bemorlarga cheklovlar


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133

qo‘yilgan bo‘lsa-da (masalan, suzish va qorin bo‘shlig’i

kateterlari bilan og’irliklarni ko‘tarish; terlash yoki

gemodializ kateteri bilan suzish va boshqalar), bu

tavsiyalar amaliyotda asoslanmagan.

Boshqa  omillar. 

Ba‘zi bemorlarda o‘z hissini

qo‘shishi mumkin bo‘lgan boshqa omillarga steroid

miyopatiyasi, kaliy almashinuvining o‘zgarishi va to‘yib

ovqatlanmaslik kiradi. Bu omillar odatda mushaklar

funksiyasining pasayishi bilan bog’liq deb tan olinadi.

Klinik  taqdim  va  tashxis. 

Uremik miyopatiya bir

qator belgilar va simptomlar bilan tavsiflanadi, shu

jumladan mushaklar kuchsizligi va proksimal va distal

mushaklarni o‘z ichiga olgan zaiflik, chidamlilik va

jismoniy mashqlar qobiliyatining pasayishi va oson

charchash [3, 42]. Koptokchalar filtratsiya tezligi

pasayishi bilan jiddiylik kuchayadi; eng og’ir holatlar

gemodializ bemorlari orasida tasvirlangan [3, 43].

Zaiflikdan tashqari, jismoniy tekshiruv o‘zgarish-

sizdir. Elektromiyografik tadqiqotlar va mushak

fermentlari ham o‘zgarishsizdir [3].

Mushak

biopsiyalari

xarakterli

strukturaviy,

elektrolitlar va fermentativ anomaliyalarni ko‘rsatadi

[3, 44–46]. Sakkizta SBK bilan kasallangan

bemorlarning mushak biopsiyalari sog’lom odamlar

bilan solishtirilgan kichik tadqiqotda yorug’lik

mikroskopida atrofiya, ayniqsa 2-toifa mushak

tolalari (ya‘ni «tez qizzaruvchan» yoki anaerobik)

va generatsiyasi va degeneratsiyasi ko‘rsatilgan

[44]. Elektron mikroskopda mitoxondrial o‘zgarishlar,

miofilamentlarning yo‘qolishi va hujayra ichidagi

glikogenning

to‘planishi

ko‘rsatilgan.

Biroq,

mushaklarning strukturaviy anormalliklari funksional

buzilishlar bilan qanchalik yaqin bog’liqligi aniq emas

[1, 2, 47].

Skrining  (profilaktik  tibbiy  ko‘rikni  o‘z  ichiga 

olgan  chora-tadbirlar  majmuasi). 

Biz gemodializ

bilan og’rigan bemorlarning ko‘pchiligini va simptomlari

ularning

birgalikdagi

kasalliklariga

mutanosib

ravishda namoyon bo‘ladigan gemodializ bo‘lmagan

SBK bemorlarini funksional cheklovlar uchun

tekshiramiz. Jismoniy ko‘rsatkichlar ma‘lum qilingan

funksional cheklash uchun skrining tekshiruvi (yurish

va zinapoyaga ko‘tarilish kabi asosiy faoliyatdagi

cheklovlar bilan belgilanadi) keyingi funksional

pasayish, nogironlik va o‘limni oshirish xavfi ostida

bo‘lgan bemorlarni aniqlashi mumkin [4, 5].

Funksional

va

harakatchanlik

cheklovlarini

baholash uchun quyidagi skrining savollari taklif

qilingan:

1. Siz 400 metrga yurish yoki 10 zinapoyaga

chiqishda qiynalayapsizmi?

2. Siz 400 metrga yurgan yo‘lingizni o‘zgar-

tirdingizmi yoki jismoniy holat tufayli buni qanchalik

tez-tez qilasiz?

Bundan tashqari, jismoniy ko‘rsatkichlar obyektiv

ravishda aniqlanishi mumkin. Jismoniy funksiyaning

bir nechta testlari mavjud bo‘lib, ularni qo‘llash oson

va odatda SBK bo‘lmagan bemorlarda qo‘llaniladi,

jumladan, olti daqiqalik yurish testi, yurishni tezlikka va

vaqtga baholash [48]. Yurish tezligini o‘lchash uchun

bemor odatdagi tezligida 3 metrdan ortiq yuradi va

kerak bo‘lganda to‘xtab, dam olishga ruxsat beriladi.

Yurish tezligi 0,8 m/s dan past bo‘lsa, SBK bilan

og’rigan bemorlarda o‘limning oshishi bilan bog’liq

[49]. Turib vaqtga yurish testida bemor to‘liq o‘tirgan

joyidan turishi va 4 metr yurishi kerak; vaqt ≥4 soniya

oshishi SBKda o‘limning oshishi bilan bog’liq.

Ko‘pgina transplantatsiya markazlari hozirda

buyrak transplantatsiyasiga yaroqlilik uchun skrining

mezonlari sifatida jismoniy funksiyaning obyektiv

o‘lchovlaridan foydalanmoqda.

Oldini  olish. 

Miopatiyani to‘liq oldini olish

mumkin emas, ayniqsa uremiya bilan bevosita bog’liq

bo‘lgan jihatlar (ya‘ni, oksidlanish shikastlanishi va

mitoxondrial ajralish). Biroq, harakatsiz turmush tarzini

oldini olish yoki davolash mushaklarning klinik jihatdan

ahamiyatli buzilishining rivojlanishini kechiktirishi

yoki yumshatishi mumkin [50]. Barcha bemorlarga

yondashuvimiz mashqlar rejimini hamda D vitamini

yetishmovchiligi, kamqonlik va ovqatlanishni optimal

davolashni o‘z ichiga oladi va quyida tavsiflanadi.

Tanlangan bemorlarda ushbu choralarga qaramay,

doimiy va zaiflashtiruvchi miopatiya va atrofiya bo‘ladi.

Bunday bemorlar fizioterapevt yoki jismoniy mashqlar

fiziologiga murojaat qilish, shuningdek, farmakologik

davolash usullaridan foydalanishlari mumkin.

Faol turmush tarzi va jismoniy mashqlar – barcha

SBK bilan og’rigan bemorlarga, shu jumladan

gemodializda bo‘lganlarga faol hayot tarzini saqlab

qolish uchun maslahat beramiz. Jismoniy faollik ko‘p

foyda keltiradi, shu jumladan mushaklar buzilishining

rivojlanishini oldini oladi [50].

Gemodializsiz SBK bilan og’rigan bemorlar – SBK

bilan og’rigan bemorlar umumiy aholi uchun mavjud

bo‘lgan aerob mashqlari, mushaklarni kuchaytirish,

moslashuvchanlik va muvozanat bo‘yicha tavsiyalarga

amal qilishlari kerak.

Gemodializ bemorlari uchun jismoniy mashqlar

miqdori bemorning imkoniyatlariga bog’liq. Mashq

qilishning oqilona dozasi kuniga kamida 4000 qadam

yurish bo‘ladi [51] va bu yondashuv, hatto keksa

bemorlarda ham [19, 52] tasodifiy sinovda ijobiy ta‘sir

ko‘rsatdi.

Biroq, funksional jihatdan cheklangan yoki

zaif odamlar hech qachon tavsiya etilgan minimal

faollik darajasiga erisha olmasligi mumkin bo‘lsa-

da, hatto oddiy faollik va mushaklarning kuchayishi

ham funksional cheklovlarning rivojlanishiga ta‘sir

qilishi mumkin [53, 54]. Jismoniy faollik bo‘yicha

tavsiyalarning barcha elementlari faoliyat rejasiga

kiritilishi kerak bo‘lsa-da, «pastdan boshlang va

sekin yuring» degan maqolni yodda tutish kerak.

Boshlang’ich nuqta sifatida kuniga ikki marta besh

daqiqa yurish bo‘yicha asosiy jismoniy faoliyat

tavsiyalarini boshlash ma’quldir. Asosiysi, bemor

o‘zini bajarishga qodir bo‘lgan harakatlar to‘plamini

aniqlash, shuning uchun o‘z-o‘zini samaradorlik

konsepsiyasini jismoniy faoliyat tavsiyalariga kiritish

[55]. Ba‘zi gemodializ markazlari, gemodializ paytida

davolash kafedrasida gemodializ markazida statsionar

velosipedni taklif qildi. Yaxshilanish ushbu oddiy

dasturdan keyin 12 hafta ichida sodir bo‘ladi, ammo


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134

bemorlarning atigi 20 foizi muntazam ravishda

qatnashadilar [56].

Peritoneal gemodializ bilan og’rigan bemorlar

gemodializ bilan og’rigan bemorlar kabi past jismoniy

ko‘rsatkichlarga ega [57]. Peritoneal gemodializ bilan

oladigan bemorlar uchun keng jamoatchilikka tavsiya

etilgan ko‘rsatmalarga rioya qilgan holda uyda cho‘zish

va yurish dasturi tavsiya etiladi [58].

Jismoniy terapiya buyrak kasalligining oxirgi

bosqichi bilan og’rigan bemorlarni parvarish qilishda

muntazam ravishda qo‘llanilmagan. Mumkin bo‘lgan

foyda bor deb hisoblansa-da, SBK oxirgi bosqichi

tashxisi qo‘yilgandan keyin fizioterapevt yoki jismoniy

mashqlar fiziologiga muntazam ravishda murojaat

qilishning foydasi, hech qanday katta sinovda

o‘rganilmagan.

Jismoniy  mashqlarning  foydasi. 

Atrofiya va

miopatiyaning oldini olish bir qator tadqiqotlar shuni

ko‘rsatdiki, mashqlar gemodializ bo‘lmagan SBK

bilan og’rigan bemorlarda, shu jumladan past oqsilli

parhezda bo‘lganlarda mushaklarning massasi va

funksiyasini saqlab qolish yoki yaxshilashga yordam

beradi [17, 18, 59–68]. Eng yaxshi ma‘lumotlar

tasodifiy sinovlarning ikkita meta-tahlilidan olingan

bo‘lib, ular mashqlar bilan mushaklar kuchini

yaxshilashni ko‘rsatdi [17, 18]. Mashqlar soni

yoki davomiyligidan qat’i nazar, SBKning barcha

bosqichlarida,

shu

jumladan

gemodializdagi

bemorlarda mushaklar kuchini yaxshilaydi [17].

Gemodializ bilan og’rigan bemorlarda mushaklar

hajmini oshadi.

Meta-tahlillardan so‘ng e’lon qilingan sinovda

gemodializdagi 296 nafar bemor tasodifiy ravishda

olti oylik yurish mashqlari dasturiga yoki odatdagi

jismoniy faoliyatga tayinlangan [19]. Olti oyda jismoniy

mashqlar guruhidagi bemorlar boshlang’ich bilan

solishtirganda o‘lchangan jismoniy ko‘rsatkichlarda

yaxshilanishni boshdan kechirdilar (olti daqiqalik yurish

masofasi va besh marta o‘tirish-turish sinov vaqti bilan

aniqlangan), odatdagi faoliyat guruhidagi bemorlar esa

bu ko‘rsatkichga ega emaslar. Bundan tashqari, yurish

mashqlari guruhidagi bemorlar odatdagi jismoniy

faollik guruhidagi bemorlarga nisbatan kasalxonaga

yotqizish darajasi pastroq (100 kishiga 57 kasalxonaga

yotqizish mos ravishda 35) va buyrak kasalliklari sifati

bo‘yicha kognitiv va ijtimoiy o‘zaro ta‘sir ko‘rsatkichlari

yaxshilangan.

KFT

pasayishining

sekinlashishi

ko‘p

tadqiqotlar shuni ko‘rsatdiki, jismoniy mashqlar

buyrak funksiyasining pasayishini sekinlashtiradi va

gemodializga muhtoj bo‘lish xavfini kamaytiradi

Uzoq muddatli ma‘lumotlar faqat kuzatuv

tadqiqotlari bilan cheklangan. Uzoq muddatli

kogort tadqiqoti to‘rt haftalik jismoniy faollik tarixi

so‘rovnomasi yordamida miqdoriy aniqlangan jismoniy

faollikni o‘rtacha 3,7 yil davomida KFTning o‘lchovi

bilan taqqosladi [70]. Haftada 150 daqiqadan ko‘proq

jismoniy faollik haqida xabar bergan shaxslar faol

bo‘lmaganlar bilan solishtirganda KFT sekinroq

pasaygan (mos ravishda yiliga 6,2 foizga 9,6 foiz).

O‘rtacha 3,7 yillik kuzatuvda haftalik faoliyatning

har 60 daqiqalik o‘sishi tuzatilgan tahlilda buyrak

funksiyasining 0,5 foizga sekin pasayishi bilan bog’liq

edi.

Yurak qon tomir tizimiga foyda – kam harakat

turmush tarzining yurak – qon tomir kasalliklari va

o‘limga salbiy ta‘siri yaxshi ma‘lum, jismoniy mashqlar

foydasi kuzatuv tadqiqotlari tomonidan taklif qilingan

[72]. Bir nechta tadqiqotlar gemodializ bilan og’rigan

bemorlarda omon qolish va jismoniy mashqlar

o‘rtasidagi bog’liqlikni o‘rganib chiqdi [71, 73, 74].

Xitoylik 6363 bemorning bir tadqiqotida piyoda

yurish gemodializsiz SBK bilan og’rigan bemorlarda

o‘limning pasayishi bilan bog’liq [71].

Gemodializ natijalari va amaliyot namunalarini

o‘rganish (DOPPS) ma‘lumotlarini tahlil qilinganda

5763 ishtirokchi jismoniy faollikning ortib borishi

darajasi, aerobik faollik o‘limning pasayishi bilan

bog’liq edi [74].

Ushbu tadqiqotda aerobik faollik salomatlik bilan

bog’liq hayot sifatining oshishi va depressiyaning

pasayishi bilan ham bog’liq edi.

Jismoniy

mashqlarning

boshqa

afzalliklari

aerob qobiliyatini va yurak qon tomir funksiyasini

yaxshilashni o‘z ichiga oladi [17], bezovta oyoq

sindromi zo‘ravonligining pasayishi va uyqu sifatining

yaxshilanishi [75], umuman hayot sifatini yaxshilash

va KDQOL-SF so‘rovnomasi [18, 9] tomonidan

baholangan ijtimoiy o‘zaro ta‘sirlarni yaxshilash.

Davolash. 

Yuqorida tavsiflangan profilaktik

davolash usullariga qaramasdan, ba‘zi bemorlarda

doimiy va zaiflashtiruvchi zaiflik bo‘ladi (odatda

yuqorida tavsiflanganidek skrining orqali aniqlanadi).

Bunday bemorlarni fizioterapevt yoki jismoniy

mashqlar

fiziologiga

yuborishdan

tashqari,

farmakologik davolash usullari testosteron va karnitin

qo‘shimchasini o‘z ichiga oladi:

Doimiy va zaiflashtiruvchi kuchsizligi bo‘lgan va

androgen terapiyasiga qarama-qarshiliklarga ega

bo‘lmagan barcha erkak bemorlarda testosteron

yetishmovchiligini baholash va agar mavjud bo‘lsa,

uch oy davomida testosteronni almashtirish terapiyasi

bilan davolash va mushaklar kuchini qayta baholash

kerak. Agar bemor mushak kuchining yaxshilanishini

ko‘rsatsa, biz testosteron terapiyasini cheksiz davom

ettiramiz. Agar bemor mushak kuchida yaxshilanishni

ko‘rsatmasa, biz testosteron terapiyasini to‘xtatamiz.

Testosteron yetishmovchiligi bo‘lmagan yoki

testosteronni

almashtirish

terapiyasiga

javob

bermaydigan gemodializdagi erkaklarda vena ichiga

L-karnitin qo‘shimchasini (haftada uch marta 1000

mgdan) uch oydan olti oygacha sinovdan o‘tkazish

mumkin. Gemodializ bilan og’rigan bemorlarda, vena

ichiga L-karnitinni qo‘llash munozarali bo‘lib qolmoqda.

Karnitin tanqisligining biokimyoviy diagnostikasi qiyin,

chunki deyarli barcha gemodializdagi bemorlarida qon

zardobidagi karnitin darajasida anormallik mavjud va

hech qanday tadqiqot turli xil qon karnitin o‘lchovlari

va mushaklar funksiyasi o‘rtasidagi bog’liqlikni

ko‘rsatmagan. L-karnitinga javob o‘ziga xos bo‘lishi

mumkin, ba‘zi bemorlarda mushaklar funksiyasining

yaxshilanishi bilan ko‘rinadi [77].


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135

Doimiy va zaiflashtiruvchi zaifligi bo‘lgan ayol

bemorlarda

biz

testosteron

yetishmovchiligini

muntazam ravishda baholamaymiz, chunki ayollarda

androgen

terapiyasining

roli

ayollarda

jinsiy

qiziqish / qo‘zg’alish (libido) buzilishi tashxisi bilan

postmenopozal ayollarni davolash bilan chegaralanadi.

Gemodializ oladigan bemorlarda L-karnitinning vena

ichiga uch oydan olti oygacha bo‘lgan sinovini erkak

bemorlar uchun yuqorida muhokama qilinganidek

ko‘rib chiqish mumkin.

Biz o‘sish gormonini bermaymiz. Insonning

rekombinant o‘sish gormoni (rhGH) ning anabolik

ta‘siri ko‘plab mushaklarni yo‘qotadigan sharoitlarda,

shu jumladan SBKda [78] qayd etilgan bo‘lsa-da,

rhGH qo‘llanilishi bilan jismoniy funksiya va kuchning

barqaror yaxshilanishini ko‘rsatadigan juda kam

ma‘lumotlar mavjud. 20 nafar bemorning platsebo-

nazoratli tadqiqotida gemodializdan so‘ng haftasiga

uch marta 66,7 mkg/kg teri osti rhGH bilan tutqich

kuchi va anabolik ta‘sir kuchayganligi qayd etildi

[79]. Xalqaro ko‘p tadqiqotli sinovida III bosqichida,

2000 dan ortiq gemodializ bemorlarining, tadqiqot

muddatdan oldin tugatildi, ammo kamida bitta dozani

qabul qilgan 695 bemorda ushlab turish kuchi yoki

yurish qobiliyati yaxshilanmadi [80].

Bashorat. 

Mushaklar kuchining pasayishi o‘limning

ortishi bilan bog’liq. Bu eng yaxshi kuzatuv tadqiqotida

ko‘rsatilgan, jumladan 330 dializ bemori, ularning

29 foizi besh yil davomida vafot etgan [4]. Kuchlari

pasaygan bemorlarda mushaklarning massasi normal

bo‘lsa ham o‘lim xavfi ortdi (xavf darajasi [HR] 1,98,

95% CI 1,01–3,87). Kuchning kamayishi bo‘lmaganda

mushak massasining kamayishi ushbu tadqiqotda

o‘limni oshirmadi. Bu shuni ko‘rsatadiki, funksional

baholash mushaklarning massasini baholashdan

tashqari prognostik ma‘lumotlarni taqdim etishi

mumkin.

Kuch va chidamlilikning pasayishi keksa

gemodiyaliz bemorlari orasida keng tarqalgan

zaiflikning muhim tarkibiy qismidir [81, 82]. Gemodializ

bemorlarda zaiflik o‘limning oshishi [82–88] va

sinishlarning ko‘payishi [89, 90], shuningdek, hayot

sifatining pasayishi [91] bilan bog’liq.

Xulosa. 

Surunkali buyrak kasalligi bilan og’rigan

bemorlarda, ayniqsa gemodializda bo‘lganlarda,

ko‘pincha mushaklarning sezilarli zaifligi va chidamliligi

yo‘q. Bu ko‘pincha harakatsiz turmush tarziga olib

keladi, bu harakatsiz turmush tarzining kuchayishiga

olib keladi va dializ bilan og’rigan bemorlarda kasallik

va o‘limni oshiradi. Jismoniy mashqlar harakatsiz

turmush tarzini ta‘sirini bekor qilishi yoki yumshatishi

va omon qolishni yaxshilashi mumkin.

Chiziqli mushaklarning mitoxondrial samarado-

rligining pasayishi SBKning dastlabki bosqichida

sodir bo‘lishi mumkin. Shundan so‘ng, mushaklarning

progressiv buzilishi harakatsiz turmush tarzidan

kelib chiqadi. Eritropoetin, D vitamini va androgen

yetishmovchiligi mushaklar kuchsizligi sababidan biri

bo‘ladi.

Biz barcha gemodializ va gemodializsiz SBK

bemorlarini funksional cheklovlarni tekshiramiz.

Jismoniy

ko‘rsatkichlarning

skrining

tekshiruvi

bemorlarda nogironlik va o‘limning oshishi xavfini

aniqlashi mumkin. Skrining savollari ishlatilishi

mumkin yoki funksional testlar yordamida jismoniy

ko‘rsatkichlar obyektiv ravishda aniqlanishi mumkin.

Harakatsiz turmush tarzini oldini olish yoki

davolash mushaklarning klinik jihatdan ahamiyatli

buzilishining rivojlanishini kechiktirishi yoki yumshatishi

mumkin. Bizning barcha bemorlarga yondashuvimiz

mashqlar

rejimi,

shuningdek,

D

vitamini

yetishmovchiligi, kamqonlik va ovqatlanishni optimal

davolashni o‘z ichiga oladi va yuqorida tavsiflangan.

Ayniqsa, jismoniy mashqlar ko‘plab afzalliklarga

ega, shu jumladan gemodializsiz SBK bilan og’rigan

bemorlarda buyrak funksiyasini saqlab qolish va yurak

qon tomir va omon qolish uchun mumkin bo‘lgan

foydadir.

Profilaktik

muolajalarga

qaramasdan,

ba‘zi

bemorlarda doimiy va zaiflashtiruvchi zaiflik

bo‘ladi. Bunday bemorlarni fizioterapevt yoki

jismoniy mashqlar fiziologiga yuborishdan tashqari,

farmakologik davolash usullari testosteron va karnitin

qo‘shimchasini o‘z ichiga oladi. Biroq, ulardan

muntazam foydalanishni tasdiqlovchi yuqori sifatli

dalillar yo‘q.

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of antihypertensive medications. Am J Kidney Dis

2002; 39:828.

57. Painter PL, Agarwal A, Drummond M. Physical

Function and Physical Activity in Peritoneal

Dialysis Patients. Perit Dial Int 2017; 37:598.

58. K/DOQI Workgroup. K/DOQI clinical practice

guidelines for cardiovascular disease in dialysis

patients. Am J Kidney Dis 2005; 45:S1.

59. Castaneda C., Gordon P.L., Uhlin K.L., et al.

Resistance training to counteract the catabolism

of a low-protein diet in patients with chronic

renal insufficiency. A randomized, controlled trial.

AnnIntern Med 2001; 135:965.

60. Clyne N. The importance of exercise training in

predialysis patients with chronic kidney disease.

Clin Nephrol 2004; 61 Suppl 1:S10.

61. Boyce M.L., Robergs R.A., Avasthi P.S., et al.

Exercise training by individuals with predialysis

renal

failure:

cardiorespiratory

endurance,

hypertension, and renal function. Am J Kidney Dis

1997; 30:180.

62. Painter P., Carlson L., Carey S., et al. Physical

functioning and health-related quality-of-life

changes with exercise training in hemodialysis

patients. Am J Kidney Dis 2000; 35:482,

63. Lo C.Y., Li L., Lo W.K., et al. Benefits of exercise

training in patients on continuous ambulatory

peritoneal dialysis. Am J Kidney Dis 1998;

32:1011.

64. DePaul V., Moreland J., Eager T., Clase C.M.

The effectiveness of aerobic and muscle strength

training in patients receiving hemodialysis and

EPO: a randomized controlled trial. Am J Kidney

Dis 2002; 40:1219.

65. Mustata S., Chan C., Lai V., Miller J.A. Impact

of an exercise program on arterial stiffness and

insulin resistance in hemodialysis patients. J Am

Soc Nephrol 2004; 15:2713.

66. van Vilsteren M.C., de Greef M.H., Huisman

R.M. The effects of a low-to-moderate intensity

preconditioning exercise programme linked with

exercise counselling for sedentary haemodialysis

patients in The Netherlands: results of a

randomized clinical trial. Nephrol Dial Transplant

2005; 20:141.

67. Cheema B., Abas H., Smith B., et al. Randomized

controlled trial of intradialytic resistance training to

target muscle wasting in ESRD: the Progressive

Exercise for Anabolism in Kidney Disease (PEAK)

study. Am J Kidney Dis 2007; 50:574.

68. Sakkas G.K., Sargeant A.J., Mercer T.H., et

al. Changes in muscle morphology in dialysis

patients after 6 months of aerobic exercise

training. Nephrol Dial Transplant 2003; 18:1854.

69. Greenwood S.A., Koufaki P., Mercer T.H., et al.

Effect of exercise training on estimated GFR,

vascular health, and cardiorespiratory fitness in

patients with CKD: a pilot randomized controlled

trial. Am J Kidney Dis 2015; 65:425.


background image

138

70. Robinson-Cohen C., Littman A.J., Duncan G.E.,

et al. Physical activity and change in estimated

GFR among persons with CKD. J Am Soc

Nephrol 2014; 25:399.

71. Chen I.R., Wang S.M., Liang C.C., et al.

Association of walking with survival and RRT

among patients with CKD stages 3–5. Clin J Am

Soc Nephrol 2014; 9:1183.

72. Kodama S., Saito K., Tanaka S., et al.

Cardiorespiratory fitness as a quantitative

predictor of allcause mortality and cardiovascular

events in healthy men and women: a meta-

analysis. JAMA 2009; 301:2024.

73. Stack A.G., Molony D.A., Rives T., et al.

Association of physical activity with mortality in

the US dialysis population. Am J Kidney Dis 2005;

45:690.

74. Lopes A.A., Lantz B., Morgenstern H., et al.

Associations of self-reported physical activity

types and levels with quality of life, depression

symptoms, and mortality in hemodialysis patients:

the DOPPS. Clin J Am Soc Nephrol 2014; 9:1702,

75. Giannaki C.D., Hadjigeorgiou G.M., Karatzaferi

C., et al. A single-blind randomized controlled trial

to evaluate the effect of 6 months of progressive

aerobic exercise training in patients with uraemic

restless legs syndrome. Nephrol Dial Transplant

2013; 28:2834.

76. Hewitt N.A., O‘Connor A.A., O‘Shaughnessy D.V.,

Elder G.J. Effects of cholecalciferol on functional,

biochemical, vascular, and quality of life outcomes

in hemodialysis patients. Clin J Am Soc Nephrol

2013; 8:1143.

77. Hurot J.M., Cucherat M., Haugh M., Fouque

D. Effects of L-carnitine supplementation in

maintenance hemodialysis patients: a systematic

review. J Am Soc Nephrol 2002; 13:708.

78. Kopple J.D. The rationale for the use of growth

hormone or insulin-like growth factor I in adult

patients with renal failure. Miner Electrolyte Metab

1992; 18:269.

79. Johannsson G., Bengtsson B.A., Ahlmén J.

Double-blind, placebo-controlled study of growth

Horm one treatment in elderly patients undergoing

chronic hemodialysis: anabolic effect and

functional improvement. Am J Kidney Dis 1999;

33:709.

80. Kopple J.D., Cheung A.K., Christiansen J.S., et al.

OPPORTUNITY™: a large-scale randomized

clinical trial of growth hormone in hemodialysis

patients. Nephrol Dial Transplant 2011; 26:4095.

81. Johansen K.L., Dalrymple L.S., Delgado C., et

al. Association between div composition and

frailty among prevalent hemodialysis patients: a

US Renal Data System special study. J Am Soc

Nephrol 2014; 25:381.

82. McAdams-DeMarco M.A., Law A., Salter M.L.,

et al. Frailty as a novel predictor of mortality

and hospitalization in individuals of all ages

undergoing hemodialysis. J Am Geriatr Soc 2013;

61:896.

83. Murray A.M. Cognitive impairment in the aging

dialysis and chronic kidney disease populations:

an occult burden. Adv Chronic Kidney Dis 2008;

15:123.

84. Li M., Tomlinson G., Naglie G., et al. Geriatric

comorbidities, such as falls, confer an

independent mortality risk to elderly dialysis

patients. Nephrol Dial Transplant 2008; 23:1396.

85. Johansen K.L., Dalrymple L.S., Glidden D.,

et al. Association of Performance-Based and

SelfReported Function-Based Definitions of

Frailty with Mortality among Patients Receiving

Hemodialysis. Clin J Am Soc Nephrol 2016;

11:626.

86. Johansen KL, Chertow GM, Jin C, Kutner NG.

Significance of frailty among dialysis patients. J

Am Soc Nephrol 2007; 18:2960.

87. Lee S.Y., Yang D.H., Hwang E., et al. The

Prevalence, Association, and Clinical Outcomes

of Frailty in Maintenance Dialysis Patients. J Ren

Nutr 2017; 27:106.

88. Kallenberg M.H., Kleinveld H.A., Dekker F.W., et

al. Functional and Cognitive Impairment, Frailty,

and Adverse Health Outcomes in Older Patients

Reaching ESRD-A Systematic Review. Clin J Am

Soc Nephrol 2016; 11:1624.

89. McAdams-DeMarco M.A., Suresh S., Law A.,

et al. Frailty and falls among adult patients

undergoing chronic hemodialysis: a prospective

cohort study. BMC Nephrol 2013; 14:224.

90. Delgado C., Shieh S., Grimes B., et al.

Association of Self-Reported Frailty with Falls and

Fractures among Patients New to Dialysis. Am J

Nephrol 2015; 42:134.

91. Iyasere O.U., Brown E.A., Johansson L., et al.

Quality of Life and Physical Function in Older

Patients on Dialysis: A Comparison of Assisted

Peritoneal Dialysis with Hemodialysis. Clin J Am

Soc Nephrol 2016; 11:423.

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van Vilsteren M.C., de Greef M.H., Huisman R.M. The effects of a low-to-moderate intensity preconditioning exercise programme linked with exercise counselling for sedentary haemodialysis patients in The Netherlands: results of a randomized clinical trial. Nephrol Dial Transplant 2005; 20:141.

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Hurot J.M., Cucherat M., Haugh M., Fouque D. Effects of L-carnitine supplementation in maintenance hemodialysis patients: a systematic review. J Am Soc Nephrol 2002; 13:708.

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Kopple J.D., Cheung A.K., Christiansen J.S., et al. OPPORTUNITY™: a large-scale randomized clinical trial of growth hormone in hemodialysis patients. Nephrol Dial Transplant 2011; 26:4095.

Johansen K.L., Dalrymple L.S., Delgado C., et al. Association between body composition and frailty among prevalent hemodialysis patients: a US Renal Data System special study. J Am Soc Nephrol 2014; 25:381.

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Li M., Tomlinson G., Naglie G., et al. Geriatric comorbidities, such as falls, confer an independent mortality risk to elderly dialysis patients. Nephrol Dial Transplant 2008; 23:1396.

Johansen K.L., Dalrymple L.S., Glidden D., et al. Association of Performance-Based and SelfReported Function-Based Definitions of Frailty with Mortality among Patients Receiving Hemodialysis. Clin J Am Soc Nephrol 2016; 11:626.

Johansen KL, Chertow GM, Jin C, Kutner NG. Significance of frailty among dialysis patients. J Am Soc Nephrol 2007; 18:2960.

Lee S.Y., Yang D.H., Hwang E., et al. The Prevalence, Association, and Clinical Outcomes of Frailty in Maintenance Dialysis Patients. J Ren Nutr 2017; 27:106.

Kallenberg M.H., Kleinveld H.A., Dekker F.W., et al. Functional and Cognitive Impairment, Frailty, and Adverse Health Outcomes in Older Patients Reaching ESRD-A Systematic Review. Clin J Am Soc Nephrol 2016; 11:1624.

McAdams-DeMarco M.A., Suresh S., Law A., et al. Frailty and falls among adult patients undergoing chronic hemodialysis: a prospective cohort study. BMC Nephrol 2013; 14:224.

Delgado C., Shieh S., Grimes B., et al. Association of Self-Reported Frailty with Falls and Fractures among Patients New to Dialysis. Am J Nephrol 2015; 42:134.

Iyasere O.U., Brown E.A., Johansson L., et al. Quality of Life and Physical Function in Older Patients on Dialysis: A Comparison of Assisted Peritoneal Dialysis with Hemodialysis. Clin J Am Soc Nephrol 2016; 11:423.

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