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
-
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
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
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].
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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