Высокая частота кардиоваскулярных заболева

Âûñîêàÿ ÷àñòîòà êàðäèîâàñêóëÿðíûõ çàáîëåâàíèé ó áîëüíûõ ñ òåðìèíàëüíîé ïî÷å÷íîé íåäîñòàòî÷íîñòüþ ïðèâëåêëà âíèìàíèå èññëåäîâàòåëåé ê
ïðîáëåìå ïîðàæåíèÿ ñåðäå÷íî-ñîñóäèñòîé ñèñòåìû
ó áîëüíûõ ÕÁÏ íà ðàííèõ ñòàäèÿõ, ò.å. ïðè óìåðåííî
ñíèæåííûõ çíà÷åíèÿõ ÑÊÔ (â ïðåäåëàõ 50-60 ìë/
ìèí), êîãäà óðîâåíü êðåàòèíèíà â ñûâîðîòêå êðîâè
íîðìàëüíûé èëè íåçíà÷èòåëüíî ïîâûøåí [1].
Âçàèìîîáóñëîâëåííîñòü ïàòîëîãè÷åñêèõ ïðîöåññîâ ñåðäå÷íî-ñîñóäèñòîé ñèñòåìû è ïî÷åê,
êëèíè÷åñêàÿ ïðåäñêàçóåìîñòü êîíå÷íûõ ðåçóëüòàòîâ, ïîçâîëÿþò ðàññìàòðèâàòü êàðäèîðåíàëüíûå
âçàèìîîòíîøåíèÿ êàê íåïðåðûâíóþ öåïü ñîáûòèé,
ñîñòàâëÿþùèõ ñâîåîáðàçíûé ïîðî÷íûé êðóã, ò.å. êàê
êàðäèîðåíàëüíûé êîíòèíóóì [1]. Â êàðäèîðåíàëüíîì
ñèíäðîìå ïðîñëåæèâàåòñÿ îò÷åòëèâàÿ ïàðàëëåëü
ìåæäó ôîðìèðîâàíèåì è ïðîãðåññèðîâàíèåì êîðîíàðíîãî è íåêîðîíàðíîãî àòåðîñêëåðîçà è ãëîìåðóëñêëåðîçà ñ ïîâûøåíèåì ðèñêà ñåðäå÷íî-ñîñóäèñòûõ
è ïî÷å÷íûõ îñëîæíåíèé.
Âçàèìîîòíîøåíèÿ ïî÷êè ñ ïàòîëîãèåé ñåðäå÷íî-ñîñóäèñòîé ñèñòåìû íîñÿò ìíîãîãðàííûé
õàðàêòåð è ÷àùå âñåãî âûñòðàèâàþòñÿ ïî ìåõàíèçìó
îáðàòíîé ñâÿçè. Ñóùåñòâîâàíèå è ôóíêöèîíèðîâàíèå îáðàòíîé ñâÿçè, â ñâîþ î÷åðåäü, ïîääåðæèâàþò
ôàê òîðû ðèñêà, äåéñòâóþùèå äâóíàïðàâëåíî è
ïðèäàþùèå âñåé êàðäèîðåíàëüíîé ñèñòåìå ïàòîãåíåòè÷åñêóþ óñòîé÷èâîñòü.
Ñèñòîëè÷åñêàÿ äèñôóíêöèÿ - ýòî íàðóøåíèå
õàðàêòåðèçóþùååñÿ ñíèæåíèåì ñîêðàòèòåëüíîé
ñïîñîáíîñòè ìèîêàðäà è âûðàæàåòñÿ â ñíèæåíèè
ôðàêöèè âûáðîñà, ôðàêöèè óêîðî÷åíèÿ âîëîêîí ìèîêàðäà, óìåíüøåíèè óäàðíîãî è ìèíóòíîãî îáúåìà è
äðóãèõ ïîêàçàòåëåé ñèñòîëè÷åñêîé ôóíêöèè ëåâîãî
æåëóäî÷êà [2]. Äàííûå î ÷àñòîòå íàðóøåíèÿ ñèñòîëè÷åñêîé ôóíêöèè ëåâîãî æåëóäî÷êà ó äèàëèçíûõ
áîëüíûõ âàðüèðóþò â øèðîêèõ ïðåäåëàõ. Íåðåäêî
ïàðàìåòðû ñèñòîëè÷åñêîé ôóíêöèè ëåâîãî æåëóäî÷êà ïðè õðîíè÷åñêîé ïî÷å÷íîé íåäîñòàòî÷íîñòè (ÕÏÍ)
ïðåâûøàþò òàêîâûå â ñðàâíèìûõ ãðóïïàõ áîëüíûõ
ñ ñîõðàííîé ôóíêöèåé ïî÷åê. London G.M. è Fabiani
F. [3] ñ÷èòàþò, ÷òî èíäóöèðóåìûå ÕÏÍ (àíåìèÿ) èëè
ñâÿçàííûå ñ ïðîâåäåíèåì äèàëèçà (àðòåðèîâåíîçíàÿ ôèñòóëà) ôàêòîðû, ïðèâîäÿ ê õðîíè÷åñêîé ïåðåãðóçêå îáúåìîì è óìåíüøåíèþ ïîñòíàãðóçêè, ìîãóò
óâåëè÷èâàòü, ñîãëàñíî ïðèíöèïó Ôðàíêà–Ñòàðëèíãà,
ñîêðàòèìîñòü ìèîêàðäà. Íåêîòîðûå èññëåäîâàòåëè
ñ÷èòàþò ñèñòîëè÷åñêóþ äèñôóíêöèþ íåõàðàêòåðíîé
äëÿ äèàëèçíûõ áîëüíûõ [4,5]. Äðóãèå íàõîäÿò åå ó
36–62% óðåìè÷åñêèõ ïàöèåíòîâ [6,7].Ïî ìíåíèþ
Palmer B.F. è Henrich W.L. [8], äàííûå î âûñîêîé
÷àñòîòå ñèñòîëè÷åñêîé äèñôóíêöèè ó áîëüíûõ ñ
ÕÏÍ êàñàþòñÿ, ïðåæäå âñåãî, ëèö, èìåâøèõ ñåðäå÷íî-ñîñóäèñòûå íàðóøåíèÿ â ïðîøëîì. Åùå áîëåå
36
âïå÷àòëÿþùåå âëèÿíèå ôóíêöèè ïî÷åê íà ïðîãíîç
áûëî îòìå÷åíî ó ëèö ñ èñõîäíîé ñåðäå÷íî-ñîñóäèñòîé ïàòîëîãèåé è äèñôóíêöèåé ëåâîãî æåëóäî÷êà
(òàáë.1) [9-12].
Òàáëèöà 1. Âëèÿíèå ôóíêöèè ïî÷åê íà ÷àñòîòó
ñåðäå÷íî-ñîñóäèñòûõ îñëîæíåíèé ó ëèö
ñ äèñôóíêöèåé ëåâîãî æåëóäî÷êà
Èññëåäîâàíèå
SOLVD
TRACE
SAVE
VALLIANT
Ãîä
×èñëî
ïàöèåíòîâ
Îòíîøåíèå ðèñêîâ
ÑÑ îñëîæíåíèé íà
êàæäûå 10 ìë/ìèí
ïàäåíèÿ ÑÊÔ
2001
2002
2003
2003
6635
6252
2184
14527
1,1
1,2
1,5
1,1
Ïðèìå÷àíèå:: SOLVD - The Studies Of Left Ventricular Dysfunction; TRACE – Trandolapril Cardiac
Evalution; SAVE – Survival and Ventricular Enlargement;
VALLIANT – Valsartan in Acute Myocardial Infarction.
Âî âñåõ ÷åòûðåõ êðóïíûõ èññëåäîâàíèÿõ ñíèæåíèå ÑÊÔ íèæå 60 ìë/ìèí àññîöèèðîâàëîñü ñ
âûñîêîé ëåòàëüíîñòüþ âñëåäñòâèå ñåðäå÷íî-ñîñóäèñòûõ îñëîæíåíèé, è ýòî íå çàâèñåëî îò äðóãèõ
ñîïóòñòâóþùèõ çàáîëåâàíèé èëè ôàêòîðîâ [12].
Îäíàêî íàðóøåíèÿ ñîêðàòèòåëüíîé ñïîñîáíîñòè ìèîêàðäà ÷àñòî îáíàðóæèâàþò ó äåòåé ñ òåðìèíàëüíîé óðåìèåé, íå ñòðàäàâøèõ ñåðäå÷íî-ñîñóäèñòûìè çàáîëåâàíèÿìè [13,14].Êðàéíèì ïðîÿâëåíèåì
ñèñòîëè÷åñêîé äèñôóíêöèè ÿâëÿåòñÿ çàñòîéíàÿ
ñåðäå÷íàÿ íåäîñòàòî÷íîñòü [7]. Îíà âûÿâëÿåòñÿ
ó 10–12% áîëüíûõ ñ ÕÏÍ è îáóñëîâëèâàåò äî 37%
îáùåé ëåòàëüíîñòè íåäèàáåòè÷åñêèõ äèàëèçíûõ ïàöèåíòîâ [15].Ïðåäëîæåí ñïåöèàëüíûé òåðìèí “óðåìè÷åñêàÿ êàðäèîïàòèÿ”, ïðèìåíÿåìûé ê ïàöèåíòàì
ñî çíà÷èòåëüíîé äèëàòàöèåé ñåðäå÷íûõ ïîëîñòåé,
íèçêèì ñåðäå÷íûì âûáðîñîì, íîðìàëüíûì èëè
íèçêèì ÀÄ, êîòîðûå ðåçèñòåíòíû ê ëþáûì ïîïûòêàì
óëüòðàôèëüòðàöèè [16]. Îïðåäåëåíèå “óðåìè÷åñêèé”
ñâèäåòåëüñòâóåò, ÷òî â äîïîëíåíèå ê îáùåïðèçíàííûì ôàêòîðàì òèïà ãèïåðòîíèè, àíåìèè, ïåðåãðóçêè
îáúåìîì [7] â ãåíåçå çàñòîéíîé êàðäèîïàòèè ó
äèàëèçíûõ áîëüíûõ îïðåäåëåííàÿ ðîëü îòâîäèòñÿ
âîçäåéñòâèþ íà ìèîêàðä óðåìè÷åñêèõ òîêñèíîâ. Àâòîðû, ïðèäåðæèâàþùèåñÿ ïðîòèâîïîëîæíîé òî÷êè
çðåíèÿ, ñ÷èòàþò, ÷òî ãåìîäèíàìè÷åñêàÿ ïåðåãðóçêà
îáúåìîì è äàâëåíèåì â ïîëíîé ìåðå îáúÿñíÿåò
ïàòîãåíåç óðåìè÷åñêîé êàðäèîïàòèè [17,18], è íàçûâàþò äèñêóññèþ ïî ïîâîäó òåðìèíà “óðåìè÷åñêèé”
ñåìàíòè÷åñêîé [19]. íåêîòîðûõ ðàáîòàõ ñîîáùàåòñÿ, ÷òî êàðäèîìåãàëèþ íåðåäêî ìîæíî îáíàðóæèòü
ó ïàöèåíòîâ, ñ÷èòàþùèõñÿ “õîðîøî êîíòðîëèðóå-
ìûìè” [17]. London G.M. è ñîàâò. [20] îáíàðóæèëè,
÷òî äèàñòîëè÷åñêèå ðàçìåðû ëåâîãî æåëóäî÷êà ó
äèàëèçíûõ ïàöèåíòîâ, õîòÿ è íàõîäÿòñÿ â ïðåäåëàõ
íîðìû, âñå æå ïðåâûøàþò òàêîâûå â êîíòðîëüíîé
ãðóïïå. Iannetti E. è Corpinteri G. [21] óêàçàëè íà ïîëîæèòåëüíóþ êîððåëÿöèîííóþ ñâÿçü ìåæäó îáúåìîì
æèäêîñòè, óäàëÿåìîé âî âðåìÿ ÃÄ, è ñèñòîëè÷åñêîé
ôóíêöèåé ëåâîãî æåëóäî÷êà.Ïðîáëåìà õðîíè÷åñêîé
ãèïåðâîëåìèè àêöåíòèðóåòñÿ åùå è ïî òîé ïðè÷èíå,
÷òî, äîáèâøèñü åå êîððåêöèè, ÷àñòî óäàåòñÿ ñïðàâèòüñÿ ñ çàñòîéíîé êàðäèîïàòèåé. ßðêîå êëèíè÷åñêîå íàáëþäåíèå Toz Í. è ñîàâò. [14] äåìîíñòðèðóåò
ïîëíóþ îáðàòèìîñòü òÿæåëîé óðåìè÷åñêîé êàðäèîïàòèè ó ãåìîäèàëèçíîé ïàöèåíòêè ïîñëå íàçíà÷åíèÿ
åé äîïîëíèòåëüíîé óëüòðàôèëüòðàöèè.Ïðè íàëè÷èè
çíà÷èòåëüíîé äèëàòàöèè ëåâîãî æåëóäî÷êà è åãî
1.
2.
3.
4.
9.
10.
11.
12.
13.
14.
16.
20.
21.
íèçêîé ñîêðàòèòåëüíîé ñïîñîáíîñòè ñðåäíÿÿ ïðîäîëæèòåëüíîñòü æèçíè áîëüíûõ ñîñòàâëÿåò 7,8 ìåñ.
[22]. Ê ýòîìó ñëåäóåò äîáàâèòü, ÷òî ó ïàöèåíòîâ íà
ÃÄ íèçêàÿ ñîêðàòèòåëüíàÿ ñïîñîáíîñòü ìèîêàðäà
ÿâëÿåòñÿ îäíèì èç ôàêòîðîâ ðèñêà ðàçâèòèÿ èíòðàäèàëèçíîé ãèïîòåíçèè [23,24].
Òàêèì îáðàçîì, áîëüøèíñòâî èç èçâåñòíûõ
ñåðäå÷íî-ñîñóäèñòûõ ôàêòîðîâ ðèñêà îäíîâðåìåííî ÿâëÿþòñÿ è ôàêòîðàìè ðèñêà âîçíèêíîâåíèÿ
õðîíè÷åñêîé áîëåçíè ïî÷åê (ÕÏÁ).  ñâÿçè ñ ýòèì,
àêòóàëüíûì ÿâëÿåòñÿ ïðîôèëàêòèêà ÕÁÏ ó ëèö ñ ñåðäå÷íî-ñîñóäèñòîé ïàòîëîãèåé è ÑÑÇ ó ëèö ñ ÕÁÏ, ÷òî
áóäåò ñïîñîáñòâîâàòü óëó÷øåíèþ âûæèâàåìîñòè,
êà÷åñòâà æèçíè è ñíèæåíèþ çàòðàò íà ëå÷åíèå ïàöèåíòîâ ñ ðàçëè÷íûìè îñëîæíåíèÿìè êàê ñî ñòîðîíû
ïî÷åê, òàê è ñåðäå÷íî-ñîñóäèñòîé ñèñòåìû.
Ñìèðíîâ À.Â., Äîáðîíðàâîâ Â.À., Êàþêîâ È.Ã. Êàðäèî-ðåíàëüíûé êîíòèíóóì: ïàòîãåíåòè÷åñêèå îñíîâû
ïðåâåíòèâíîé íåôðîëîãèè íåôðîëîãèÿ, 2005, (9);3: 7-15
Ðûáàêîâà Ì.Ê. Îöåíêà ñèñòîëè÷åñêîé ôóíêöèè ëåâîãî è ïðàâîãî æåëóäî÷êîâ. Êëèíè÷åñêîå ðóêîâîäñòâî
ïî óëüòðàçâóêîâîé äèàãíîñòèêå. Ò. 5. Ïîä ðåä. Ìèòüêîâà Â.Â., Ñàíäðèêîâà Â.À. Ì.: Âèäàð, 1998;
119–137.
London J.M., Fabiani F. Left ventricular dysfunction in end-stage renal disease: echocardiographic insights.
Cardiac dysfunction in chronic uremia. Eds. P.S. Parfrey, J.D. Harnett // Norwell. 1992. V. 8. P. 117–137.
Covic A., Goldsmith D.J.A., Georgescu G. et al. Echocardiographic findings in long-term, long-hour
hemodialysis patients // Clin. Nephrol. 1996. V. 45.
2. P. 104–110.5. Raj D.S.C., Mello S., Somiah S. et al.
Left ventricular morphology in chronic renal failure by echocardiography // Renal Fail. 1997. V. 19.
6. P.
799–806.6. Greaves S.C., Gamble G.D., Collins J.F. et al. Determinants of left ventricular hypertrophy and
systolic dysfunction in chronic renal failure // Am. J. Kidney Dis. 1994. V. 24.
5. Ð. 768–776.7. Harnett J.D.,
Foley R.N., Kent G.M. et al. Congestive heart failure in dialysis patients: prevalence, incidence, prognosis
and risk factors // Kidney Int. 1995. V. 47. P. 884–890.8. Palmer B.F., Henrich W.L. The effect of dialysis of
left ventricular contractility. Cardiac dysfunction in chronic uremia. Eds. P.S. Parfey, J.D. Harnett // Ibid.
Chapt. V. 11. P. 172–185.
Al Ahmad A, Rand WM, Manjunath g et al. Reduced kidney function and anemia as risk factors for mortality
in patients with left ventricular dysfunction. J Am Cool Cardiol 2001; 38: 955-962
Sorensen CR, Brendorp Brask-Madsen C et al. The prognostic importance of the creatinine clearance after
acute myocardial infarction. Eur Heart J 2002; 23: 948-952
Anavekar NS, Me Murray JV, Velazguez EJ et al. Relation between renal dysfunction and cardiovascular
outcomes after myocardial infarction. N Engl J Med 2004; 351: 13
Anavekar NS, Preffer MA. Cardiovascular risk in chronic kidney disease. Kidney Int 2004; 66 [Suppl 92]:
S11-S15
Dimitriu A., Nistor N., Brumariu O., Condurache T. Echocardiographic evaluation of the cardiac disorders
in chronic renal failure in children // Eur. J. Echocard. 1999. V. 1. P. 102.
Toz H., Ozerkan F., Unsal A. et al. Dilated uremic cardiomyopathy in a dialysis patient cured by persistent
ultrafiltration // Am. J. Kidn. Dis. 1998. V. 32.
4. P. 664–668.15. Áàãðèé À.Ý. Õàðàêòåðèñòèêà ñåðäå÷íîñîñóäèñòûõ íàðóøåíèé ó áîëüíûõ ñ õðîíè÷åñêîé ïî÷å÷íîé íåäîñòàòî÷íîñòüþ // Âðà÷. äåëî. 1997;3:
57–60.
Drueke T., Le Pailleur C., Meilhac B. et al. Congestive cardiomyopathy in uraemic patients on longterm haemodialysis // Br. Med. J. 1977. V. 1. P. 350–353.17. Ikram H., Lynn K.L., Bailey R.R., Little P.J.
Cardiovascular changes in chronic hemodialysis patients // Kidney Int. 1983. V. 24. P. 371–376.18. Dorhout
Mees E.J. Volaemia and blood pressure in renal failure: have old truth been forgotten? // Nephrol. Dial.
Transplant. 1995. V. 10. P. 1297–1298.19. Hung J., Harris P.J., Uren R.F. et al. Uremic cardiomyopathy: effect
of hemodialysis on left ventricular function in end-stage renal failure // N. Engl. J. Med. 1980. V. 302. P.
547–551.
London G.M., Marchais S.J., Guerin A.P. et al. Cardiac hypertrophy and arterial alterations in end-stage
renal disease: hemodynamic factors // Kidney Int. 1993. V. 43. P. 42–49.
Iannetti E., Corpinteri G. Cardiac function and extracellular water relationship in hemodialysis // J. Nephrol.
1996. V. 9.
6. P. 295–298.22. Weinrauch L.A., D’Elia J.A., Gleason R.E. et al. Usefulness of left ventricular
size and function in predicting survival in chronic dialysis patients with diabetes mellitus // Am. J. Cardiol.
1992. V. 70.
3. P. 300–303.23. Rozich J.D., Smith B., Thomas J.D. et al. Dialysis-induced alterations in left
ventricular filling: mechanisms and significance // Am. J. Kidney Dis. 1991. V. 17. P. 277–285.24. Constantino
M.L., Cairo G., Fumero R. Haemodynamic alteration in patients undergoing chronic haemodialysis // Int. J.
Artif. Organs. 1997. V. 20.
10. P. 610–613
37