戴希文治疗慢性肾脏病的经验总结
摘要
1.研究目的
戴希文教授是广安门医院肾内科的名老专家,临证40余载,对诊治慢性肾脏病(CKD)具有独到的经验。戴教授诊治CKD的经验已通过临床总结、临床研究、实验研究等方式进行整理、验证及阐释。本研究意在通过数据挖掘方法及“人机结合、以人为主”的数据解析方法进行戴教授临床经验总结,进一步挖掘戴教授对CKD的临床诊疗规律,进而总结和补充戴教授治疗CKD的学术思想。
2.研究方法
本研究采集戴希文教授门诊病历102份,共计480诊次,通过将门诊病历录入临床信息采集系统,建立戴希文教授临床诊疗信息综合数据库,利用临床要素多维关系实时在线展示技术、复杂网络分析方法、点式互信法等数据挖掘技术获得结果,分别以症状、证候、治法、方药等临床要素以及CKD分期为线索初步分析、整理戴老诊治CKD的临床经验,就初步挖掘分析结果与戴老进行访谈,通过“人机结合,以人为主”的方法对结果进行筛选及解析,并结合以往研究结果总结戴老治疗CKD的临床思维模式、诊疗经验及学术观点。
3.研究结果——戴老诊治CKD的经验
3.1对症状的认识
本研究CKD患者最常见的舌脉是舌质暗或暗红,舌体胖,或见边有齿痕,舌苔薄、黄、腻,脉象细滑；最常见的症状是腰痛、乏力、大便偏稀、浮肿、口干、睡眠差、小便泡沫多、咽部红肿、咽痛、咽部有痰。体现了戴老重视对CKD患者舌脉、精神体力状况、浮肿情况、口干情况、二便情况以及咽部不适等四诊要素的诊察,并以此为辨证的基础。
3.2对病机的认识
本次研究显示CKD总病机是正虚邪实,正虚以肺脾肾三脏气虚为主,兼有阴虚、血虚,邪实以血瘀风热湿毒为主,兼有浊邪、水邪。其中,气虚湿瘀是CKD的核心病机,贯穿于CKD的全过程,常与他邪相兼为病；风热毒邪作为令疾病加重的外部因素,常常伴随CKD病程,并以CKD早期更为明显,亦是戴老非常重视的证候；而随着CKD的进展,水邪、浊邪逐渐出现,是CKD的病理产物和致病因素,正气因而进一步衰败,出现气血两虚,符合戴老对病机的认识。
3.3治则治法的运用
以扶正祛邪为总治则,治法以益气活血,清热解毒利湿为主,根据兼夹证辅以利水泄浊、滋阴、养血等。针对CKD不同分期,CKD1-2期以益气活血,清热解毒利湿为主,CKD3-4期以益气活血,清热利水湿泄浊为为主,CKD5期则益气养血活血,利水湿泄浊为主,兼以和中。
3.4方剂运用规律
本研究中最常用方剂为银翘散、玉屏风散、当归芍药散、防己黄芪汤以及自拟方。其中自拟方有益气养血活血,清热解毒利湿泄浊之效。
银翘散针对慢性咽炎以及外感风热之邪广泛运用于各种CKD；玉屏风散常用于尿血、水肿、腰痛、紫斑等中医疾病以及慢性肾炎、肾性高血压等疾病的治疗；当归芍药散、防己黄芪汤多用于水肿、虚劳等中医疾病以及高血压肾病、肾性高血压、慢性肾衰竭等西医疾病的的治疗,自拟方主要用于虚劳—慢性肾衰竭的治疗。
对于CKD1-2期以玉屏风散、银翘散合用较多,CKD3-5期以当归芍药散、防己黄芪汤、自拟方运用较多。
研究结果符合戴老常用玉屏风散、银翘散加减益气固表,清热解毒,疏散外邪,治疗慢性肾炎；当归芍药散合防己黄芪汤加减活血利水,治疗肾性高血压、肾性水肿；益气养血活血、利湿泄浊中药加减治疗慢性肾衰竭的临床经验。
3.5用药规律
使用频次最多的15味药物为生黄芪、当归、连翘、白花蛇舌草、白芍、赤芍、金银花、太子参、车前草、穿山龙、茯苓、炒白术、大青叶、川芎、防风。是此次研究的核心药物。体现了戴老扶正祛邪的治疗原则,益气活血,清热解毒利湿的治疗方法。
使用种类最多的10类药为：清热药、补虚药、理气药、利水渗湿药、解表药、化痰药、活血化瘀药、止血药、安神药、消食药；使用频次最多的5类药物分别是补虚药、清热药、利水渗湿药、止血药、活血化瘀药。
随证加减用药19组：
1.针对水湿证的用药：黄芩-牛膝-益母草-泽泻、猪苓-商陆-汉防己、桑白皮-大腹皮活血利水消肿,用于肾性高血压、肾性水肿的治疗。
2.针对阴血亏虚,血瘀气滞等证的用药：知母-黄柏、南沙参-北沙参养阴清肺泻火,用于激素副作用的治疗以及慢性咽炎、肺阴虚干咳的治疗；女贞子-墨旱莲养肝肾阴,治疗肝肾阴虚所致的耳鸣；枳壳-郁金-黄精益气养阴、活血宽胸,治疗气阴两虚,气滞血瘀所致的胸闷；丹参-生地-白鲜皮、生地-熟地-鸡血藤-代赭石、生地-熟地-续断-香附滋阴养血调经,用于血虚生风、月经不调。
3.针对热灼血络的用药：侧柏-仙鹤草-地榆炭、大蓟-小蓟凉血止血,可用于血尿的治疗。
4.针对中下焦湿滞证的用药：黄连-木香、黄连-制吴茱萸、黄连-瓜蒌-枳实、藿梗-紫苏梗辛开苦降、化湿和中,可用于中焦湿滞的治疗；川楝子-败酱草-白头翁清热解毒利湿,用于下焦湿热的治疗。
6.其他加减：土贝母-海蛤壳软坚散结,用于乳腺结块的治疗,煅龙骨-煅牡蛎收敛固涩兼补钙,用于自汗、骨关节病的治疗。
CKD1-5期用药规律：CKD1-2期配伍加减以清热解毒,凉血利湿药物为主；CKD3-4期加减用药则以活血利水泄浊为主；CKD5期加减用药除以上特点外,更注重养血及理气和中。
4.戴老学术思想总结
4.1辨证结合辨病,融贯中西医
戴老对于CKD的认识,主张辩证与辨病相结合。对于症状不明显的CKD患者,戴老主张结合现代医学对CKD的病理机制认识进行辨证,同时主张深入了解疾病的发展过程及预后。
4.2把握邪正虚实,重视邪实病机
戴老认为CKD病机总属正虚邪实。CKD初期,以邪实为主,CKD后期,正气虚损更为明显,而湿热则贯穿于CKD发病、发展的全过程,常与瘀血、浊邪、水邪、风毒等互结而致疾病缠绵难愈,因此戴老对于湿热的清利贯穿于治疗的始终。
4.3掌握动态平衡,气血水同治
戴老认为,CKD的发生,往往伴随气血水的失衡,治疗肾性性水肿、肾性高血压等疾病时,戴老常气血水同治,调节三者的动态平衡。
4.4治法分层次,用药有法度
4.4.1扶正不壅补,祛邪有出路
戴老治疗CKD坚持扶正治疗,主要予平补气血阴阳之品,少用滋腻碍胃之药,及桂附等辛热之品。同时,戴老主张给邪以出路,疏解风热表邪；清解热毒之邪；渗利水湿之邪；燥化中焦湿滞；清利下焦湿热；降泄浊邪。
4.4.2活血不伤血,止血不留瘀
CKD常兼有血瘀,戴老往往辨证施治,血热兼瘀者予以凉血化瘀；血瘀水停者,予以活血利水；血虚兼瘀者,予以养血活血；气滞血瘀者,予以活血行气；表现为血尿者,治予凉血止血配合收涩止血；久病化瘀通淋；虚证明显,予收涩止血；活血不用峻猛破血之药,止血配伍活血养血。
4.4.3药味精准,一药双关
戴老临证重视药味的精准,为达到治疗效果常使用一些双关药。
4.5重视兼夹证,善用经验药
由于各种感染常为CKD的致病因素和加重因素,戴老很重视对此类兼夹证的治疗,并擅用经验药。如风热袭表,常用银花、连翘、大青叶、地丁、荆芥穗疏风清热解毒；痰热蕴肺,予黄芩、鱼腥草清肺化痰；上焦热毒,常予蒲公英、蛇莓等清解热毒；湿滞中焦,常用木香、黄连清热燥湿理气；下焦湿热,常予白头翁、蒲公英、鱼腥草等清热利湿通淋等。对于合并水邪者,则以活血利水之益母草、牛膝,利水消肿之泽泻、猪苓等治之；浊毒内蕴者,合用焦大黄或生大黄以通腑泄浊。
4.6长期调治,配合食疗,以平为期
戴老认为CKD需要长期调治,对CKD早期的病人,治疗目的以减少蛋白尿、血尿,防治感染等加重因素为主,对于CKD后期的患者,则以延缓肾功能进展,防治合并症,改善生活质量为主。戴老根据不同疾病的特点,倡导病人进行食疗。
1.Objective
Professor XiWen Dai is a famous senior nephrology expert working in Guang'anmen Hospital.In more than fourty years's clinical practice, she sets up some special methods to treat the Chronic Kidney Disease (CKD), which have been summarized, testified and explained. This study is intended to summarize and further explore the clinical experiences and CKD diagnosis and treatment laws of Prof Dai through Data Mining and analysing, the character of which is "Man-Computer Cooperation and mainly by man", so as to supplement and summarize her CKD academic ideology.
2. Methods
Through the Structural Clinical Information Collection System we made the database of Prof Dai and obtained the result by the technologies of on line analyze process (OLAP), free-scale network and pointwise mutual information(PMI).Then we analyzed and summarized Prof Dai's clinical experiences in treating CKD based on CKD stage and syndrome factors,such as symptom, syndrome, therapeutic method, prescription, herbal medicine-and so on.Then we got an interview with doctor Dai and make selections and explainations of the result. We summarized the thinking mode, clinical experiences and the learning point of view of Prof Dai combining with results of our past studies.
3. Results—the clinical experiences of Prof Dai in treating CKD
3.1 The view of symptoms
This study indicates that the most common tongue manifestations and the pulse manifestations were:dark or dark red tongue, bulgy tongue or teeth-printed tongue, with thin, yellow or greasy coating, thready pulse or slippery pulse; the most frenquent symptom are low back pain, lack of power, loose stool, edema, dry mouth, insomnia, foam urine, pharynx intumescence, sore throat, phlegm. The result reflect doctor Dai's experience that attach importance to these symptoms and take them as the basis of syndrome differentiation.
3.2 The view of pathogenesis
This study reveals that the general pathogenesis of CKD is deficiency of vital qi and excess of pathogen.defiency of vital qi included the deficiency of lung qi, the deficiency of spleen qi and the deficiency of kidney qi, or accompanied with yin deficiency, blood deficiency. State of evil domination mainly included blood stasis, wind heat, damp toxin, or accompanied with turbid pathogen or water pathogen. Deficiency of qi,blood stasis and turbid damp are the central pathogenesis of CKD,they go through the whole process of CKD and tend to combine with other pathogens.Wind heat and toxin pathogen are the external cause which can aggravate the disease,and it is more obvious in the early stage of CKD.They are both the cause and the production of the disease. In the progress of CKD, water pathogen and turbid pathogen aggravate gradually, and further impair the healthy qi,and then become insufficiency of both qi and blood. The result accords with Prof Dai's view of pathogenesis.
3.3 The application of therapeutic principle and theroputic methods
The general therapeutic principle is to strengthen vital qi and dispel exogenous pathogen. The main therapeutic methods are to benefit vital qi and activate blood, clear away the heat evil and expel superficial evils and eliminate dampness, or combine with the methods such as inducing diuresis,check turbidity downward, nourishing yin, nourishing blood according to accompanied syndromes.According to different stages of CKD,their therapeutic methods are varies from each other. For stage 1-2 of CKD, the methods focus on strengthening qi and activating blood, clearing up heat,removing toxicity and draining dampness.For stage 3-4 of CKD, it's turning to strengthen qi and activate blood, clear up heat,inducing diuresis,check turbidity downward. For the last stage, the methods should focus on strengthening qi, nourishing and activating blood, clearing up heat,inducing diuresis,checking turbidity downward, or combining with regulating stomach.
3.4 The application of prescriptions
The most frequently used of prescriptions in this study are Honeysuckle Forsythia Powder, Jade-Screen Powder, Chinese Angelica and Peony Powder, Tetrandra and Astragalus Decoction and self-made prescription. The self-made prescription has the function of replenishing qi,promoting and nourishing the blood, dispersing the dampness and checking turbidity downward.
Honeysuckle Forsythia Powder, aiming at Chronic pharyngitis and exogenous pathogens of wind heat, has been broadly used in various kinds of CKD;Jade-Screen Powder tends to be applied to hematuria, edema, lumbago and purpura, chronic nephritis and renal hypertension and so on; Chinese Angelica and Peony Powder and Tetrandra and Astragalus Decoction are used to treat TCM diseases,such as edema, consumption diseases and western medicine diseases like hypertensive nephropathy, renal hypertension and chronic renal failure; The self-made prescription is used to treat consumption diseases—chronic renal failure.
For patients in CKD 1 or 2, Jade-Screen Powder and Honeysuckle Forsythia Powder are mainly used, when it came to stage3-5, Chinese Angelica and Peony Powder, Tetrandra and Astragalus Decoction are mainly used.
The result accords with Prof Dai's experiences that using modified Honeysuckle Forsythia Powder and Jade-Screen Powder to replenishing qi to strengthen superficial defence,clearing away the heat evil and expelling superficial evils,dispelling external pathogens so as to treat chronic nephritis;using modified Chinese Angelica and Peony Powder, Tetrandra and Astragalus Decoction to activate blood and excrete the water so as to treat renal hypertension and renal edema; using prescriptions with functions of replenishing qi,promoting and nourishing the blood, dispersing the dampness and checking turbidity downward to treat chronic renal failure.
3.5 Administration laws of chinese herbal drugs
The most frequently used of 15 chinese herbal drugs are:Shenghuangqi, Danggui, Lianqiao, Baihuasheshecao, Baishao,Chishao, Jinyinhua, Taizishen, Cheqiancao, Chuanshanlong, Fuling, Chaobaizhu, Daqingye, Chuanxiong, Fangfeng. These chinese herbal drugs are the core drugs in this research and reflect the therapeutic principle, which is strengthen vital qi and dispel exogenous pathogen and the therapeutic methods as replenishing qi,promoting and nourishing the blood, dispersing the dampness and checking turbidity downward.
To the medication classification, the 10 kinds of chinese herbs which have been used most frequently are:heat-clearing herbs, tonic herbs, herbs that regulate the qi, herbs that promote urination and leach out dampness, herbs that release the exterior syndrome, herbs that eliminate the phlegm, herbs that promote blood circulation to remove stasis, herbs that arrest bleeding,herbs that calm the spirit,herbs that remove food stagnation and reduce mass;the 5 kinds of herbs which have been used most frequently are:tonic herbs, heat-clearing herbs, herbs that promote urination and leach out dampness, herbs that arrest bleeding, herbs that promote blood circulation to remove stasis.
19 modification herb groups according to different syndromes:
1.Focus on the dampness:These groups include Huangqin-Niuxi-Yimucao-Zexie, Zhuling-Shanglu-Hanfangji,Powdergbaipi-Dafupi,which have the function to promote blood circulation, promote urination and leach out dampness, and have been used to treat renal hypertention and renal edema.
2.Focus on the syndromes like deficiency of yin and blood, stagnation of qi and blood:Zhimu-Huangbai, Nanshashen-Beishashen,which have the function of clearing heat-fire and can be used to treat the side-effect of glucocorticoid,chronic pharyngitis and hacking cough caused by the deficiency of lung yin; Nvzhenzi-Mohanlian have the function of nourishing yin of liver and kidney to eliminate tinnitus caused by yin deficiency of liver and kidney; Zhike-Yujin-Huangjing have the function of promoting qi, nourishing yin, activating blood and regulate qi,and to be used for Chest stuffiness. Danshen-Shengdi-Baixianpi, Shengdi-Shudi-Jixueteng-Daizheshi,Shengdi-Shudi-Xuduan-Xiangfu have functions of nourishing yin and blood, regulating menstruation, and to be used for endogenous wind caused by deficiency of blood and irregular menstruation.
3.Focus on the syndrome of vessel injured by heat:Cebai-Xianhecao-Diyutan, Daji-Xiaoji are used to cooling blood for hemostasis.
4.Focus on the damp obstruction in the middle or the lower jiao: Huanglian-Muxiang, Huanglian-Zhiwuzhuyu, Huanglian-Gualou-Zhishi,and Huogeng-Zisugeng are used to removing dampness for regulating stomach to treat the dampness stagnation of middle energizer, Chuanlianzi-Baijiangcao-Baitouweng have the efficacy of clearing heat toxicity and draining dampness to treat dampness heat of lower energizer.
5.Others:Tubeimu-Haigeke have the efficacy of softening and resolving hard mass, and be used to treat breast lump.Duanlonggu-Duanmuli have the efficacy of astringing and supplying calcium and can be used to treat spontaneous sweating and osteoarthropathy.
medication laws in CKD 1-5:Modificating for stage1 or 2 of CKD,herbs that heat-clearing,promote urination and leach out dampness are mainly used; in stage 3 or 4, herbs that promote blood circulation to remove stasis, promote urination and leach out dampness are mainly used; in the 5th stage of CKD, therapeutic methods of nourishing blood and regulating qi have been further used.
4. Academic ideology of Prof Dai
4.1 Combining syndrome differenciation with differentiation of disease and integrating traditional and western medicine
Prof Dai advocates that syndrome differentiation should be combined with differentiation of disease in treating CKD.As some patients don't have typical symptoms, Prof Dai hold that syndrome differenciation should refer to the pathological mechanism of CKD, at the same time, the course and the prognosis of the disease should be thoroughly understood.
4.2 Judging deficiency and excess of pathogen and vital qi, attaching importance to excess of pathogen
Prof Dai holds that the general pathogenesis of CKD is deficiency of vital qi and excess of pathogen. In the early stage of CKD, excess of pathogen dominates the disease, while in the later stage of CKD,deficiency of vital qi became more obvious. As dampness heat pathogen is throughout the course of CKD and tend to be accompanied by pathogens like blood stasis, turbidity, water and wind toxicity, which leading to the difficulty to cure the disease. Thus, the therapeutic methods of clearing heat and draining dampness are used throughout the course of CKD.
4.3 Treating qi, blood and water pathogen at the same time to keep their dynamic equilibrium
Prof Dai considers that the morbidity of CKD is often accompanied by the unbalanced amone qi, blood and water pathogen. So she used to treat qi, blood and water pathogen at the same time to keep their dynamic equilibrium,especially for diseases like renal edema, ranal hypertension, etc.
4.4 Differing therapeutic methods based on syndromes and applicating herbal medicine with proper laws
4.4.1 Promoting vital qi without stagnation, eliminating pathogens in different ways: In treating CKD, Prof Dai persists in promoting vital qi, reinforcing yin, yang, qi and blood moderately. Keeping from Zi greasy herbs or pungent and warm herbs. Eliminating pathogens in different ways-expelling the superficial pathogens of wind heat, clearing heat and removing toxicity, inducing diuresis and excreting dampness, eliminating dampness of middle energizer, clearing heat and draining dampness of lower energizer, checking turbidity downward.
4.4.2 Activating blood without impairing it, stanching blood without causing stasis: Blood stasis is the common pathogen of CKD.Prof Dai's therapeutic methods about it is based on the syndrome differenciation. For the syndrome of blood heat and stagnation, blood cooling and activating are used; for the syndrome of blood stasis and water stagnation, blood activating and diuresis inducing are used; nourishing blood and activating blood are used to treat the syndrome of blood deficiency and stasis; activating blood and regulating qi are used to treat the syndrome of qi stagnation and blood stasis. The therapeutic methods for hematuria are cooling blood,which have been always combined with astringent. Herbs with strong effects of removing blood stasis is avoided, nourishing and activating of blood are often used in hemostasis.
4.4.3 Accurate application of herbal medicine and making full use of medication efficacy:Prof Dai attaches importance to the accurate application of herbal medicine and make full use of medication efficacy to obtain the satisfactory curative effect.
4.5 Attaching importance to accompanied syndromes with tested medication
Prof Dai holds that varies of infection are either pathogenic factors or aggravating factors of CKD, so she think highly of the treatment of these accompanied syndromes and takes good use of tested medication in treating them. Herbal medicines like Yinhua, Lianqiao, Dqqingye, Diding, Jingjiesui are used to expell the wind heat and remove the toxicity in treating syndrome of superficies attacked by wind-heat;Huangqin, Yuxingcao are used to clear the lung heat for removing phlegm in treating syndrome of accumulation of phlegm and heat in the lung. Treating syndrome of heat toxicity of upper energizer with Pugongying, Shemei to clear up the heat toxicity. To the dampness stagnation of middle energizer, Muxiang, Huanglian are used to climinate dampness and regulate qi.To the dampness heat of lower energizer, Baitouweng, Pugongying, Yuxingcao are used to drain dampness and promote urination. To the accompanied water pathogen,Prof Dai applied with Yimucao, Niuxi, Zexie, Zhuling to activating blood, inducing diuresis and eliminate edema. Jiaodahuang or Shengdahuang are used to discharge turbidity to treat syndrome of accumulation of turbid pathogen.
4.6 Advocating long-term treatment with dietary therapy to obtain a favourable prognosis
Prof Dai hold that patients of CKD need long-term treatment. The goal of treatment for CKD patients of early stage is to eliminate proteinuria and hematuresis and keep from infections. While in the later stage, the goal is to slow down the progress of CKD, prevent and treat complications and improve the quality of life. At the same time, referring to the characteristic of different diseases, Prof Dai advocate the application of dietary therapy.
戴希文教授是广安门医院肾内科的名老专家,临证40余载,对诊治慢性肾脏病(CKD)具有独到的经验。戴教授诊治CKD的经验已通过临床总结、临床研究、实验研究等方式进行整理、验证及阐释。本研究意在通过数据挖掘方法及“人机结合、以人为主”的数据解析方法进行戴教授临床经验总结,进一步挖掘戴教授对CKD的临床诊疗规律,进而总结和补充戴教授治疗CKD的学术思想。
2.研究方法
本研究采集戴希文教授门诊病历102份,共计480诊次,通过将门诊病历录入临床信息采集系统,建立戴希文教授临床诊疗信息综合数据库,利用临床要素多维关系实时在线展示技术、复杂网络分析方法、点式互信法等数据挖掘技术获得结果,分别以症状、证候、治法、方药等临床要素以及CKD分期为线索初步分析、整理戴老诊治CKD的临床经验,就初步挖掘分析结果与戴老进行访谈,通过“人机结合,以人为主”的方法对结果进行筛选及解析,并结合以往研究结果总结戴老治疗CKD的临床思维模式、诊疗经验及学术观点。
3.研究结果——戴老诊治CKD的经验
3.1对症状的认识
本研究CKD患者最常见的舌脉是舌质暗或暗红,舌体胖,或见边有齿痕,舌苔薄、黄、腻,脉象细滑；最常见的症状是腰痛、乏力、大便偏稀、浮肿、口干、睡眠差、小便泡沫多、咽部红肿、咽痛、咽部有痰。体现了戴老重视对CKD患者舌脉、精神体力状况、浮肿情况、口干情况、二便情况以及咽部不适等四诊要素的诊察,并以此为辨证的基础。
3.2对病机的认识
本次研究显示CKD总病机是正虚邪实,正虚以肺脾肾三脏气虚为主,兼有阴虚、血虚,邪实以血瘀风热湿毒为主,兼有浊邪、水邪。其中,气虚湿瘀是CKD的核心病机,贯穿于CKD的全过程,常与他邪相兼为病；风热毒邪作为令疾病加重的外部因素,常常伴随CKD病程,并以CKD早期更为明显,亦是戴老非常重视的证候；而随着CKD的进展,水邪、浊邪逐渐出现,是CKD的病理产物和致病因素,正气因而进一步衰败,出现气血两虚,符合戴老对病机的认识。
3.3治则治法的运用
以扶正祛邪为总治则,治法以益气活血,清热解毒利湿为主,根据兼夹证辅以利水泄浊、滋阴、养血等。针对CKD不同分期,CKD1-2期以益气活血,清热解毒利湿为主,CKD3-4期以益气活血,清热利水湿泄浊为为主,CKD5期则益气养血活血,利水湿泄浊为主,兼以和中。
3.4方剂运用规律
本研究中最常用方剂为银翘散、玉屏风散、当归芍药散、防己黄芪汤以及自拟方。其中自拟方有益气养血活血,清热解毒利湿泄浊之效。
银翘散针对慢性咽炎以及外感风热之邪广泛运用于各种CKD；玉屏风散常用于尿血、水肿、腰痛、紫斑等中医疾病以及慢性肾炎、肾性高血压等疾病的治疗；当归芍药散、防己黄芪汤多用于水肿、虚劳等中医疾病以及高血压肾病、肾性高血压、慢性肾衰竭等西医疾病的的治疗,自拟方主要用于虚劳—慢性肾衰竭的治疗。
对于CKD1-2期以玉屏风散、银翘散合用较多,CKD3-5期以当归芍药散、防己黄芪汤、自拟方运用较多。
研究结果符合戴老常用玉屏风散、银翘散加减益气固表,清热解毒,疏散外邪,治疗慢性肾炎；当归芍药散合防己黄芪汤加减活血利水,治疗肾性高血压、肾性水肿；益气养血活血、利湿泄浊中药加减治疗慢性肾衰竭的临床经验。
3.5用药规律
使用频次最多的15味药物为生黄芪、当归、连翘、白花蛇舌草、白芍、赤芍、金银花、太子参、车前草、穿山龙、茯苓、炒白术、大青叶、川芎、防风。是此次研究的核心药物。体现了戴老扶正祛邪的治疗原则,益气活血,清热解毒利湿的治疗方法。
使用种类最多的10类药为：清热药、补虚药、理气药、利水渗湿药、解表药、化痰药、活血化瘀药、止血药、安神药、消食药；使用频次最多的5类药物分别是补虚药、清热药、利水渗湿药、止血药、活血化瘀药。
随证加减用药19组：
1.针对水湿证的用药：黄芩-牛膝-益母草-泽泻、猪苓-商陆-汉防己、桑白皮-大腹皮活血利水消肿,用于肾性高血压、肾性水肿的治疗。
2.针对阴血亏虚,血瘀气滞等证的用药：知母-黄柏、南沙参-北沙参养阴清肺泻火,用于激素副作用的治疗以及慢性咽炎、肺阴虚干咳的治疗；女贞子-墨旱莲养肝肾阴,治疗肝肾阴虚所致的耳鸣；枳壳-郁金-黄精益气养阴、活血宽胸,治疗气阴两虚,气滞血瘀所致的胸闷；丹参-生地-白鲜皮、生地-熟地-鸡血藤-代赭石、生地-熟地-续断-香附滋阴养血调经,用于血虚生风、月经不调。
3.针对热灼血络的用药：侧柏-仙鹤草-地榆炭、大蓟-小蓟凉血止血,可用于血尿的治疗。
4.针对中下焦湿滞证的用药：黄连-木香、黄连-制吴茱萸、黄连-瓜蒌-枳实、藿梗-紫苏梗辛开苦降、化湿和中,可用于中焦湿滞的治疗；川楝子-败酱草-白头翁清热解毒利湿,用于下焦湿热的治疗。
6.其他加减：土贝母-海蛤壳软坚散结,用于乳腺结块的治疗,煅龙骨-煅牡蛎收敛固涩兼补钙,用于自汗、骨关节病的治疗。
CKD1-5期用药规律：CKD1-2期配伍加减以清热解毒,凉血利湿药物为主；CKD3-4期加减用药则以活血利水泄浊为主；CKD5期加减用药除以上特点外,更注重养血及理气和中。
4.戴老学术思想总结
4.1辨证结合辨病,融贯中西医
戴老对于CKD的认识,主张辩证与辨病相结合。对于症状不明显的CKD患者,戴老主张结合现代医学对CKD的病理机制认识进行辨证,同时主张深入了解疾病的发展过程及预后。
4.2把握邪正虚实,重视邪实病机
戴老认为CKD病机总属正虚邪实。CKD初期,以邪实为主,CKD后期,正气虚损更为明显,而湿热则贯穿于CKD发病、发展的全过程,常与瘀血、浊邪、水邪、风毒等互结而致疾病缠绵难愈,因此戴老对于湿热的清利贯穿于治疗的始终。
4.3掌握动态平衡,气血水同治
戴老认为,CKD的发生,往往伴随气血水的失衡,治疗肾性性水肿、肾性高血压等疾病时,戴老常气血水同治,调节三者的动态平衡。
4.4治法分层次,用药有法度
4.4.1扶正不壅补,祛邪有出路
戴老治疗CKD坚持扶正治疗,主要予平补气血阴阳之品,少用滋腻碍胃之药,及桂附等辛热之品。同时,戴老主张给邪以出路,疏解风热表邪；清解热毒之邪；渗利水湿之邪；燥化中焦湿滞；清利下焦湿热；降泄浊邪。
4.4.2活血不伤血,止血不留瘀
CKD常兼有血瘀,戴老往往辨证施治,血热兼瘀者予以凉血化瘀；血瘀水停者,予以活血利水；血虚兼瘀者,予以养血活血；气滞血瘀者,予以活血行气；表现为血尿者,治予凉血止血配合收涩止血；久病化瘀通淋；虚证明显,予收涩止血；活血不用峻猛破血之药,止血配伍活血养血。
4.4.3药味精准,一药双关
戴老临证重视药味的精准,为达到治疗效果常使用一些双关药。
4.5重视兼夹证,善用经验药
由于各种感染常为CKD的致病因素和加重因素,戴老很重视对此类兼夹证的治疗,并擅用经验药。如风热袭表,常用银花、连翘、大青叶、地丁、荆芥穗疏风清热解毒；痰热蕴肺,予黄芩、鱼腥草清肺化痰；上焦热毒,常予蒲公英、蛇莓等清解热毒；湿滞中焦,常用木香、黄连清热燥湿理气；下焦湿热,常予白头翁、蒲公英、鱼腥草等清热利湿通淋等。对于合并水邪者,则以活血利水之益母草、牛膝,利水消肿之泽泻、猪苓等治之；浊毒内蕴者,合用焦大黄或生大黄以通腑泄浊。
4.6长期调治,配合食疗,以平为期
戴老认为CKD需要长期调治,对CKD早期的病人,治疗目的以减少蛋白尿、血尿,防治感染等加重因素为主,对于CKD后期的患者,则以延缓肾功能进展,防治合并症,改善生活质量为主。戴老根据不同疾病的特点,倡导病人进行食疗。
1.Objective
Professor XiWen Dai is a famous senior nephrology expert working in Guang'anmen Hospital.In more than fourty years's clinical practice, she sets up some special methods to treat the Chronic Kidney Disease (CKD), which have been summarized, testified and explained. This study is intended to summarize and further explore the clinical experiences and CKD diagnosis and treatment laws of Prof Dai through Data Mining and analysing, the character of which is "Man-Computer Cooperation and mainly by man", so as to supplement and summarize her CKD academic ideology.
2. Methods
Through the Structural Clinical Information Collection System we made the database of Prof Dai and obtained the result by the technologies of on line analyze process (OLAP), free-scale network and pointwise mutual information(PMI).Then we analyzed and summarized Prof Dai's clinical experiences in treating CKD based on CKD stage and syndrome factors,such as symptom, syndrome, therapeutic method, prescription, herbal medicine-and so on.Then we got an interview with doctor Dai and make selections and explainations of the result. We summarized the thinking mode, clinical experiences and the learning point of view of Prof Dai combining with results of our past studies.
3. Results—the clinical experiences of Prof Dai in treating CKD
3.1 The view of symptoms
This study indicates that the most common tongue manifestations and the pulse manifestations were:dark or dark red tongue, bulgy tongue or teeth-printed tongue, with thin, yellow or greasy coating, thready pulse or slippery pulse; the most frenquent symptom are low back pain, lack of power, loose stool, edema, dry mouth, insomnia, foam urine, pharynx intumescence, sore throat, phlegm. The result reflect doctor Dai's experience that attach importance to these symptoms and take them as the basis of syndrome differentiation.
3.2 The view of pathogenesis
This study reveals that the general pathogenesis of CKD is deficiency of vital qi and excess of pathogen.defiency of vital qi included the deficiency of lung qi, the deficiency of spleen qi and the deficiency of kidney qi, or accompanied with yin deficiency, blood deficiency. State of evil domination mainly included blood stasis, wind heat, damp toxin, or accompanied with turbid pathogen or water pathogen. Deficiency of qi,blood stasis and turbid damp are the central pathogenesis of CKD,they go through the whole process of CKD and tend to combine with other pathogens.Wind heat and toxin pathogen are the external cause which can aggravate the disease,and it is more obvious in the early stage of CKD.They are both the cause and the production of the disease. In the progress of CKD, water pathogen and turbid pathogen aggravate gradually, and further impair the healthy qi,and then become insufficiency of both qi and blood. The result accords with Prof Dai's view of pathogenesis.
3.3 The application of therapeutic principle and theroputic methods
The general therapeutic principle is to strengthen vital qi and dispel exogenous pathogen. The main therapeutic methods are to benefit vital qi and activate blood, clear away the heat evil and expel superficial evils and eliminate dampness, or combine with the methods such as inducing diuresis,check turbidity downward, nourishing yin, nourishing blood according to accompanied syndromes.According to different stages of CKD,their therapeutic methods are varies from each other. For stage 1-2 of CKD, the methods focus on strengthening qi and activating blood, clearing up heat,removing toxicity and draining dampness.For stage 3-4 of CKD, it's turning to strengthen qi and activate blood, clear up heat,inducing diuresis,check turbidity downward. For the last stage, the methods should focus on strengthening qi, nourishing and activating blood, clearing up heat,inducing diuresis,checking turbidity downward, or combining with regulating stomach.
3.4 The application of prescriptions
The most frequently used of prescriptions in this study are Honeysuckle Forsythia Powder, Jade-Screen Powder, Chinese Angelica and Peony Powder, Tetrandra and Astragalus Decoction and self-made prescription. The self-made prescription has the function of replenishing qi,promoting and nourishing the blood, dispersing the dampness and checking turbidity downward.
Honeysuckle Forsythia Powder, aiming at Chronic pharyngitis and exogenous pathogens of wind heat, has been broadly used in various kinds of CKD;Jade-Screen Powder tends to be applied to hematuria, edema, lumbago and purpura, chronic nephritis and renal hypertension and so on; Chinese Angelica and Peony Powder and Tetrandra and Astragalus Decoction are used to treat TCM diseases,such as edema, consumption diseases and western medicine diseases like hypertensive nephropathy, renal hypertension and chronic renal failure; The self-made prescription is used to treat consumption diseases—chronic renal failure.
For patients in CKD 1 or 2, Jade-Screen Powder and Honeysuckle Forsythia Powder are mainly used, when it came to stage3-5, Chinese Angelica and Peony Powder, Tetrandra and Astragalus Decoction are mainly used.
The result accords with Prof Dai's experiences that using modified Honeysuckle Forsythia Powder and Jade-Screen Powder to replenishing qi to strengthen superficial defence,clearing away the heat evil and expelling superficial evils,dispelling external pathogens so as to treat chronic nephritis;using modified Chinese Angelica and Peony Powder, Tetrandra and Astragalus Decoction to activate blood and excrete the water so as to treat renal hypertension and renal edema; using prescriptions with functions of replenishing qi,promoting and nourishing the blood, dispersing the dampness and checking turbidity downward to treat chronic renal failure.
3.5 Administration laws of chinese herbal drugs
The most frequently used of 15 chinese herbal drugs are:Shenghuangqi, Danggui, Lianqiao, Baihuasheshecao, Baishao,Chishao, Jinyinhua, Taizishen, Cheqiancao, Chuanshanlong, Fuling, Chaobaizhu, Daqingye, Chuanxiong, Fangfeng. These chinese herbal drugs are the core drugs in this research and reflect the therapeutic principle, which is strengthen vital qi and dispel exogenous pathogen and the therapeutic methods as replenishing qi,promoting and nourishing the blood, dispersing the dampness and checking turbidity downward.
To the medication classification, the 10 kinds of chinese herbs which have been used most frequently are:heat-clearing herbs, tonic herbs, herbs that regulate the qi, herbs that promote urination and leach out dampness, herbs that release the exterior syndrome, herbs that eliminate the phlegm, herbs that promote blood circulation to remove stasis, herbs that arrest bleeding,herbs that calm the spirit,herbs that remove food stagnation and reduce mass;the 5 kinds of herbs which have been used most frequently are:tonic herbs, heat-clearing herbs, herbs that promote urination and leach out dampness, herbs that arrest bleeding, herbs that promote blood circulation to remove stasis.
19 modification herb groups according to different syndromes:
1.Focus on the dampness:These groups include Huangqin-Niuxi-Yimucao-Zexie, Zhuling-Shanglu-Hanfangji,Powdergbaipi-Dafupi,which have the function to promote blood circulation, promote urination and leach out dampness, and have been used to treat renal hypertention and renal edema.
2.Focus on the syndromes like deficiency of yin and blood, stagnation of qi and blood:Zhimu-Huangbai, Nanshashen-Beishashen,which have the function of clearing heat-fire and can be used to treat the side-effect of glucocorticoid,chronic pharyngitis and hacking cough caused by the deficiency of lung yin; Nvzhenzi-Mohanlian have the function of nourishing yin of liver and kidney to eliminate tinnitus caused by yin deficiency of liver and kidney; Zhike-Yujin-Huangjing have the function of promoting qi, nourishing yin, activating blood and regulate qi,and to be used for Chest stuffiness. Danshen-Shengdi-Baixianpi, Shengdi-Shudi-Jixueteng-Daizheshi,Shengdi-Shudi-Xuduan-Xiangfu have functions of nourishing yin and blood, regulating menstruation, and to be used for endogenous wind caused by deficiency of blood and irregular menstruation.
3.Focus on the syndrome of vessel injured by heat:Cebai-Xianhecao-Diyutan, Daji-Xiaoji are used to cooling blood for hemostasis.
4.Focus on the damp obstruction in the middle or the lower jiao: Huanglian-Muxiang, Huanglian-Zhiwuzhuyu, Huanglian-Gualou-Zhishi,and Huogeng-Zisugeng are used to removing dampness for regulating stomach to treat the dampness stagnation of middle energizer, Chuanlianzi-Baijiangcao-Baitouweng have the efficacy of clearing heat toxicity and draining dampness to treat dampness heat of lower energizer.
5.Others:Tubeimu-Haigeke have the efficacy of softening and resolving hard mass, and be used to treat breast lump.Duanlonggu-Duanmuli have the efficacy of astringing and supplying calcium and can be used to treat spontaneous sweating and osteoarthropathy.
medication laws in CKD 1-5:Modificating for stage1 or 2 of CKD,herbs that heat-clearing,promote urination and leach out dampness are mainly used; in stage 3 or 4, herbs that promote blood circulation to remove stasis, promote urination and leach out dampness are mainly used; in the 5th stage of CKD, therapeutic methods of nourishing blood and regulating qi have been further used.
4. Academic ideology of Prof Dai
4.1 Combining syndrome differenciation with differentiation of disease and integrating traditional and western medicine
Prof Dai advocates that syndrome differentiation should be combined with differentiation of disease in treating CKD.As some patients don't have typical symptoms, Prof Dai hold that syndrome differenciation should refer to the pathological mechanism of CKD, at the same time, the course and the prognosis of the disease should be thoroughly understood.
4.2 Judging deficiency and excess of pathogen and vital qi, attaching importance to excess of pathogen
Prof Dai holds that the general pathogenesis of CKD is deficiency of vital qi and excess of pathogen. In the early stage of CKD, excess of pathogen dominates the disease, while in the later stage of CKD,deficiency of vital qi became more obvious. As dampness heat pathogen is throughout the course of CKD and tend to be accompanied by pathogens like blood stasis, turbidity, water and wind toxicity, which leading to the difficulty to cure the disease. Thus, the therapeutic methods of clearing heat and draining dampness are used throughout the course of CKD.
4.3 Treating qi, blood and water pathogen at the same time to keep their dynamic equilibrium
Prof Dai considers that the morbidity of CKD is often accompanied by the unbalanced amone qi, blood and water pathogen. So she used to treat qi, blood and water pathogen at the same time to keep their dynamic equilibrium,especially for diseases like renal edema, ranal hypertension, etc.
4.4 Differing therapeutic methods based on syndromes and applicating herbal medicine with proper laws
4.4.1 Promoting vital qi without stagnation, eliminating pathogens in different ways: In treating CKD, Prof Dai persists in promoting vital qi, reinforcing yin, yang, qi and blood moderately. Keeping from Zi greasy herbs or pungent and warm herbs. Eliminating pathogens in different ways-expelling the superficial pathogens of wind heat, clearing heat and removing toxicity, inducing diuresis and excreting dampness, eliminating dampness of middle energizer, clearing heat and draining dampness of lower energizer, checking turbidity downward.
4.4.2 Activating blood without impairing it, stanching blood without causing stasis: Blood stasis is the common pathogen of CKD.Prof Dai's therapeutic methods about it is based on the syndrome differenciation. For the syndrome of blood heat and stagnation, blood cooling and activating are used; for the syndrome of blood stasis and water stagnation, blood activating and diuresis inducing are used; nourishing blood and activating blood are used to treat the syndrome of blood deficiency and stasis; activating blood and regulating qi are used to treat the syndrome of qi stagnation and blood stasis. The therapeutic methods for hematuria are cooling blood,which have been always combined with astringent. Herbs with strong effects of removing blood stasis is avoided, nourishing and activating of blood are often used in hemostasis.
4.4.3 Accurate application of herbal medicine and making full use of medication efficacy:Prof Dai attaches importance to the accurate application of herbal medicine and make full use of medication efficacy to obtain the satisfactory curative effect.
4.5 Attaching importance to accompanied syndromes with tested medication
Prof Dai holds that varies of infection are either pathogenic factors or aggravating factors of CKD, so she think highly of the treatment of these accompanied syndromes and takes good use of tested medication in treating them. Herbal medicines like Yinhua, Lianqiao, Dqqingye, Diding, Jingjiesui are used to expell the wind heat and remove the toxicity in treating syndrome of superficies attacked by wind-heat;Huangqin, Yuxingcao are used to clear the lung heat for removing phlegm in treating syndrome of accumulation of phlegm and heat in the lung. Treating syndrome of heat toxicity of upper energizer with Pugongying, Shemei to clear up the heat toxicity. To the dampness stagnation of middle energizer, Muxiang, Huanglian are used to climinate dampness and regulate qi.To the dampness heat of lower energizer, Baitouweng, Pugongying, Yuxingcao are used to drain dampness and promote urination. To the accompanied water pathogen,Prof Dai applied with Yimucao, Niuxi, Zexie, Zhuling to activating blood, inducing diuresis and eliminate edema. Jiaodahuang or Shengdahuang are used to discharge turbidity to treat syndrome of accumulation of turbid pathogen.
4.6 Advocating long-term treatment with dietary therapy to obtain a favourable prognosis
Prof Dai hold that patients of CKD need long-term treatment. The goal of treatment for CKD patients of early stage is to eliminate proteinuria and hematuresis and keep from infections. While in the later stage, the goal is to slow down the progress of CKD, prevent and treat complications and improve the quality of life. At the same time, referring to the characteristic of different diseases, Prof Dai advocate the application of dietary therapy.
引文
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2. Garg A X, Kiberd B A, Clark W F, et al. Albuminuria and renal insufficiency prevalence guides population screening:results from the NHANESⅢ. Kindney Int,2002,61(6):2165-2175.
3. Chadban S J, Briganti E M, Kerr P G, et al. Prevalence of kidney damage in australian adults:the AusDiab kidney study. J Am SocNephrol,2003,14(7 Suppl 2):131-138.
4. Kunitoshi I, Kentaro K, Atsushi S, et al. Changes in the demographics and prevalence of chronic kidney disease in Okinawa,Japan(1993 to 2003) Hypertens Res,2007,30(1):55-62.
5. 张路霞,左力.北京市石景山地区中老年人群中慢性肾脏病的流行病学研究.中华肾脏病杂志,2006,22(2)：67-71.
6. 陈香美.CKD的发病机制及治疗进展.2008年浙江省肾脏病学术年会.
7. Klahr S, Levey AS, Beck G, et al. The effects of dietary protein restriction and blood-pressure control on progression of chronic renal disease. N Engl J Med,1994,330: 877.
8.沈淑琼.慢性肾脏病疾病进展的危险因素与干预措施.肾脏病与透析抑制杂志,2003,12(4)：375-378.
9.刘章锁,王沛.K/DOQI指南关于慢性肾脏病分期的临床指导意义.中国实用内科杂志,2008,28(1)：1-3.
10. Jose, P., Skali, H.,Anavekar, N., Tomson, C., Krumholz, H. M., Rouleau, J. L. Moye, L., Pfeffer, M. A., Solomon, S. D., for the SAVE Investigators, (2006). Increase in Creatinine and Cardiovascular Risk in Patients with Systolic Dysfunction after Myocardial Infarction. J. Am. Soc. Nephrol.17:2886-2891
11. The ONTARGET Investigators Telmisartan, Ramipril, or Both in Patients at High Risk for Vascular Events. NEJM. Volume 358:1547-1559.
12.. Lewis EJ,et al. The effect angiotension-converting-enzyme inhibition on diabetic nephropathy. N Engl J Med,1993,329:1456.
13. Brenner BM,CooperME,De ZeeuWD,et al. Effects of losartan on renal and cardiovascular
outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med,2001,345:861.
14. Palmer A J,Annemans L,Roze S,et al.An economic evaluation of irbesartan in the treatment of patients with type 2 diabetes,hypertension and nephropathy:cost-effectiveness of Irbesartan in Diabetic Nephropathy Trail(IDNT) in the Belgian and Frencl setting[J].Nephrol Dial Transplant,2003,10(18):2059-2066.
15. Maschio G,,Alberti D,Locatelli F,et al.Angiotention-converting enzyme inhibitors and kidney protection:the AIPRI trail The ACE Inhibition in Progressive Rena Insufficiency(AIPRI) Study Group J Cardiovasc Pharmacol,1993,33(supp 1):S162261.
16. Agodoa LY,Appel L,Bakris GL,et al. African American Study of Kidney Disease and Hypertension (AASK) Study Group. Effect of ramipril vs amlodopine on renal outcomes in hypertensive nephrosclerosis:A randomized controlled trail. JAMA,2001,285(21):2719-2728.
17. Ruggenenti P,Perna A,Gherardi G,et al. Renal function and requirement for dialysis in chronic nephropathy patients on long-term ramipril:REIN follow-up trail. Gruppo Italiano di Studi Ep idemiologici in Nefrologia(GISEN).Lancet,1998,352(9136):1252-1256.
18.赵宇,占水立,饶向荣等.460例慢性肾衰竭患者中医证候特征分析.第21次中华中医药学会肾病分会学术会议论文汇编：436-439.
19.孙卫卫,刘忠杰,张恩等.慢性肾脏疾病3,4,5期中医证候学的临床研究.北京中医药大学学报(中医临床版),2009,16(5)：14-16.
20.戴希文,饶向荣.中西医结合治疗肾小球肾炎.中国中西医结合肾病杂志,2006,7(1)1-3.
21.沈庆法,中医肾脏病学.上海中医药大学出版社,2008.
22.饶向荣,吴瑞英.戴希文治疗慢性肾功能不全的经验.江西中医药,1995,26(4)：6-10.
23.沈庆法.肾病与湿热.上海中医药杂志,1982,16(3)：10.
24.赵金铎.肾炎治疗宜存精去粗兼顾.肾炎尿毒症专辑.中医古籍出版社,1988：145.
25. Nicholls AJ.Renal Dysfunction In Handbook of dialysis Boston..Baillie ClinGastroenterol Nutr,1994:673-683.
26.陈兴强,叶任高.急进性肾炎的中医治疗.吉林中医药,2000,(4)：21.
27.焦安钦,徐进秀.滋阴活血解毒法治疗原发性肾小球疾病探讨.山东中医杂志,2001,20(5)：323-325.
28.刘玉宁.陈以平教授治疗肾脏病的临床经验探讨.中国中西医结合肾病杂志,2006, 7(11)：624-625.
29.许筱颖,郭霞珍.浊毒致病理论初探.辽宁中医药杂志,2007,34(1)：28.
30.吴深涛.糖尿病病机的启变要素—浊毒.上海中医药大学学报,2004,18(1)：25.
31.冷伟,杨霓芝,赵代鑫.益气活血法防治肾纤维化的探讨与研究.江苏中医药,2009,41(5)：59-60.
32.余颜,陈杭军,林宏初等.益气补肾活血辅助治疗早期糖尿病肾病的临床观察.中国中西医结合肾病志,2005,6(7)：389-392.
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