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慢性腎臓病患者における座位行動・身体活動と筋力および骨密度の関連性

吉岡, 将輝 筑波大学

2023.09.04

概要

博士学位論文
要約版

慢性腎臓病患者における座位行動・身体活動と
筋力および骨密度の関連性

令和 4 年度
筑波大学大学院 人間総合科学学術院

人間総合科学研究群

スポーツ医学学位プログラム
吉岡

将輝

目次
研究業績 ....................................................................................................................................... 1
第 1 章 序論 ................................................................................................................................. 2
1.1. 研究の背景 ....................................................................................................................... 2
1.2. 目的 ................................................................................................................................... 4
1.3. 仮説 ................................................................................................................................... 5
第 2 章 文献研究 ......................................................................................................................... 6
2.1. CKD について .................................................................................................................. 6
2.1.1. 腎臓の機能と働き .................................................................................................... 6
2.1.2. CKD とは ................................................................................................................... 8
2.1.3. CKD と身体機能 ..................................................................................................... 10
2.1.4. CKD において筋力が低下するメカニズム.......................................................... 10
2.1.5. CKD において骨密度が低下するメカニズム...................................................... 11
2.1.6. CKD と運動 ............................................................................................................. 12
2.1.7. CKD と身体活動 ..................................................................................................... 13
2.2. 身体活動について ......................................................................................................... 14
2.2.1. 身体活動を測定する意義 ...................................................................................... 14
2.2.2. 身体活動の測定方法 .............................................................................................. 15
2.2.3. Isotemporal substitution (IS) モデル ....................................................................... 20
第 3 章 本研究の構成 ............................................................................................................... 26
第 4 章 本研究で用いた定義と評価方法 ............................................................................... 27
4.1. CKD の定義 .................................................................................................................... 27
4.2. 糖尿病の定義 ................................................................................................................. 27
4.3. 身体特性の評価方法 ..................................................................................................... 28
4.4. 座位行動・身体活動の評価方法 ................................................................................. 28
4.5. 筋力の評価方法 ............................................................................................................. 29
4.6. 骨密度の評価方法 ......................................................................................................... 30
第 5 章 研究課題 1 .................................................................................................................... 32
5.1. CKD 患者における座位行動・身体活動と筋力の関連: 横断研究.......................... 32
5.1.1. 研究の背景 .............................................................................................................. 32
5.1.2. 目的 .......................................................................................................................... 33
5.1.3. 仮説 .......................................................................................................................... 33
5.1.4. 方法 .......................................................................................................................... 33
5.1.4.1. 調査対象とデータ収集 ................................................................................... 33
5.1.4.2. 測定項目 ........................................................................................................... 36

5.1.4.3. 統計解析 ........................................................................................................... 37
5.1.5. 結果 .......................................................................................................................... 40
5.1.6. 考察 .......................................................................................................................... 47
5.1.7. 結論 .......................................................................................................................... 49
5.2. CKD 患者における座位行動・身体活動と骨密度の関連: 横断研究...................... 50
5.2.1. 研究の背景 .............................................................................................................. 50
5.2.2. 目的 .......................................................................................................................... 51
5.2.3. 仮説 .......................................................................................................................... 51
5.2.4. 方法 .......................................................................................................................... 51
5.2.4.1. 調査対象とデータ収集 ................................................................................... 51
5.2.4.2. 測定項目 ........................................................................................................... 52
5.2.4.3. 統計解析 ........................................................................................................... 53
5.2.5. 結果 .......................................................................................................................... 54
5.2.6. 考察 .......................................................................................................................... 60
5.2.7. 結論 .......................................................................................................................... 62
謝辞 ............................................................................................................................................. 64
参考文献 ..................................................................................................................................... 65

研究課題 2 以降の内容は学術ジャーナルへの投稿を予定しているため、論文掲載後公開
予定である。

研究業績
本論文は、下記の研究業績に未発表の研究成果を加えてまとめたものである。

Yoshioka M, Kosaki K, Matsui M, Takahashi K, Shibata A, Oka K, Kuro-o M, Saito C, Yamagata
K, Maeda S. (2021) Physical activity, sedentary behavior, and skeletal muscle strength in patients
with chronic kidney disease: an Isotemporal substitution approach. Phys Ther 101, 1-7.

Yoshioka M, Kosaki K, Matsui M, Shibata A, Oka K, Kuro-o M, Saito C, Yamagata K, Maeda
S. (2021) Replacing sedentary time for physical activity on bone density in patients with chronic
kidney disease. J Bone Miner Metab 39, 1091-1100.

吉岡 将輝, 小﨑 恵生, 松井 公宏, 黒尾 誠, 柴田 愛, 斎藤 知栄, 山縣 邦弘, 岡 浩一
朗, 前田 清司. (2022) 加速度計で調査した血管・腎・身体機能測定会参加者の身体活動:
地域住民および腎臓内科外来患者を対象とした調査. 運動疫学研究 (印刷中).

1

第 1 章 序論
1.1. 研究の背景
慢性腎臓病 (chronic kidney disease; CKD) は、腎障害や腎機能低下が持続する非感染
性疾患である。2015 年の報告において、我が国では約 1480 万人が CKD であると推定
されており、特に中高齢者ではその有病率が高い (Nagai et al., 2021) 。一方、先行研究
において、腎機能の指標である推算糸球体濾過量 (estimated glomerular filtration rate;
eGFR) が低値を示すほど骨格筋量が減少した病態であるサルコペニアや心身の脆弱性
が出現した状態を示すフレイルの割合が高値を示すことが報告されている (Foley et al.,
2007; Reese et al., 2013) 。加えて、韓国で実施された一般成人 10,589 名を対象とした横
断研究において、サルコペニアやフレイルは尿中アルブミン/クレアチニン比の上昇に
独立して関与すること、さらにその関与は高齢者でより顕著であることが報告されてい
る (Kim et al., 2016) 。CKD 患者におけるサルコペニアやフレイルは、透析、入院、死
亡 の 独立 した 危険 因子で あ り、 日常 生活 動作や 生 活の 質の 低下 に強く 関 与す る
(Roshanravan et al., 2013; Prasad et al., 2019; Iseri et al., 2020) 。米国で実施された CKD 患
者 271 名を対象とした調査では、研究対象者の約半数が自立した生活を維持することが
健康上の最優先課題であると認識していたと報告されている (Ramer et al., 2018) 。これ
らの報告から CKD 患者においてサルコペニアとフレイルを予防することは重要である。
筋力および骨密度はサルコペニアとフレイルの発症を予測する因子である
(Morishita et al., 2014; Roshanravan et al., 2017) 。先行研究において、腎機能の低下に伴
うインスリン抵抗性の上昇は、筋たんぱく質を分解するユビキチン・プロアテソーム系
を活性化し、筋力を低下させること報告されている (Workeneh & Mitch, 2010) 。実際、
CKD ステージ 2~4 の中高齢者において腎機能の指標である eGFR は、握力や等尺性膝
伸展筋力と正の関連性を示すことが報告されている (Hiraki et al., 2013) 。加えて、CKD
患者では、腎機能低下に伴う骨ミネラル代謝異常によって骨吸収が骨形成を上回り、骨
2

密度が低下する (Isakova et al., 2017; Zheng et al., 2016) 。先行研究において、CKD 患者
は腎機能が正常な中高齢者と比較して骨粗鬆症の有病率が高値を示すことが報告され
ている (Kuipers et al., 2015) 。これらの報告から、CKD 患者がサルコペニアとフレイル
を予防するために、筋力および骨密度の低下を抑制する方策を確立することは重要な課
題であると考えられる。
一方、ヒトの 1 日の覚醒時間は座位行動と身体活動に大別される。座位行動は座位、
半臥位、もしくは臥位状態で行われるエネルギー消費量が 1.5 メッツ以下の全ての覚醒
行動と定義される (Sedentary Behaviour Research Network, 2012) 。一方、身体活動は安静
にしている状態より多くのエネルギーを消費する全ての動作を指す (Caspersen et al.,
1985) 。ヒトが 1 日に使える時間は有限であり、各活動時間には相互依存性がある。例
えば、中高強度身体活動時間を 10 分増やすためには、他の行動を 10 分減らす必要があ
る。最近はこの相互依存性を考慮し、健康寿命を延伸するために座位行動を減らし、身
体活動を増加させることが推奨されている (Bull et al., 2020) 。先行研究において腎機
能は座位時間と負の関連を示し、低強度身体活動時間や中高強度身体活動時間と正の関
連を示すことが報告されている (Hawkins et al., 2011; Martens et al., 2018) 。この報告は、
CKD 患者は CKD ではない同年代者と比較して座位時間が増加し、低強度身体活動時間
や中高強度身体活動時間が減少していることを示唆している。したがって、CKD 患者
における座位行動・身体活動は筋力および骨密度の低下を抑制するための改善可能な介
入標的になる可能性がある (Chilibeck et al., 1995; Roshanravan et al., 2017) 。しかし、以
前より、CKD 患者に対しては安静が治療の 1 つと考えられてきた。したがって、CKD
患者における座位行動・身体活動に関する研究成果は不足しており (Kohzuki, 2018) 、
CKD 患者における座位行動・身体活動と筋力および骨密度の関連は十分に明らかにさ
れていない。

3

CKD 患者における座位行動・身体活動と筋力の関連についての先行研究としては、
身体活動と筋力が関連することを示唆するレビュー論文が複数報告されている一方で
(Roshanravan et al., 2017; Roshanravan & Patel, 2019) 、CKD 患者における座位行動・身体
活動と筋力の関連は報告されていない。CKD 患者における座位行動・身体活動と骨密
度の関連についての先行研究としては、システマティックレビューが 1 編報告されてい
る (Cardoso et al., 2020) 。その中で身体活動を客観的に評価した研究が 2 編あるが、い
ずれも総身体活動量しか評価しておらず一致した見解も得られていない。一方、近年、
加速度計を用いることで座位行動と強度別の身体活動 (低強度身体活動と中高強度身
体 活 動 ) を 客 観 的 に 精 度 高 く 評 価 す る こ と が 可 能 に な っ た (Oshima et al., 2010;
Ohkawara et al., 2011; Kurita et al., 2017) 。 ...

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