小儿频复发性肾病中医证型与病理类型的相关性分析
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摘要
目的：通过对小儿频复发性肾病(FRNS)的中医辨证分型与肾脏病理类型表现的综合分析研究，旨在探讨小儿频复发性肾病的中医证型与病理类型的相关性内在规律，为小儿频复发性肾病的中医临床辨证施治和疗效、预后判断提供客观指标和理论依据。
方法：选择50例FRNS患儿，在肾穿前按照中医四诊合参，进行辨证分型。肾穿活检标本分送光镜、免疫荧光、电镜检查，进行病理诊断。在治疗前后和治疗期间进行血、尿常规，血生化，24小时尿蛋白定量和尿沉渣检查，肾功能检查，免疫功能检查等。综合分析中医证型与临床、病理类型的关系。同时采用中西医结合的治疗方法，观察各型疗效以及0.5、1.0、1.5年的复发情况。结果以SPSS10.0统计软件进行分析。
结果：本组中医证型以肝肾阴虚(16／50)、脾肾阳虚(12／50)为主，其次为湿热内蕴(9／50)和肾虚血瘀(9／50)，气阴两虚较少见(4／50)。临床分型中，肾炎型38例，单纯型12例。肾炎型和单纯型中肝肾阴虚、脾肾阳虚、湿热内蕴、肾虚血瘀型均相对较多，而气阴两虚型较少。临床分型与中医证型的分布无显著差别。病理类型以MsPGN(17／50)、MsPGN+FSGS(13／50)和IgAN(12／50)为主，少数为IgMN、MN、MPGN和FGN。MsPGN中以肝肾阴虚多见(9／17)，二者之间呈显著正相关(r=0.938，P＜0.05)；MsPGN+FSGS主要见于肝肾阴虚、脾肾阳虚和肾虚血瘀(各4／13)，证型与病理类型之间无显著相关(r=0.827，P＞0.05)：IgAN中湿热内蕴多见(5／12)，二者呈显著正相关(r=0.895，P＜0.05)。中医证型疗效以肝肾阴虚、湿热内蕴和肾虚血瘀三型有效率较高，均在87.5％以上，且三者间无显著差异(P＞0.05)，而脾肾阳虚和气阴两虚型有效率分别为
福窟中医学脂2口04届描床…硕.于研兑生.学介讼丈
41.67%和50.00%。经统计处理，各型的总体疗效比较差异显著(尸<0.05);脾肾
阳虚型与前三型的疗效比较，差异均显著(尸<0.05);气阴两虚型与其它证型比
较无显著差异(P>.05)。复发情况比较，中医证型间总体复发率比较无显著差
异。肾虚血癖型在随访0.5年、1年和1 .5年的复发次数、复发率均较其它型低，
而脾肾阳虚型的复发次数、复发率较高。其中在1.5年，以上两型复发率比较有
显著差异(P<0.05)。
结论:
1.小儿FRNS中医辨证分型以肝肾阴虚、脾肾阳虚为主，其次为湿热内蕴和肾
虚血癖，气阴两虚较少。
2.小儿FRNs的病理类型以MspGN、MspGN+FSGS、IgAN为多见，IgMN、
MPGN、MN、FGN较少。病理类型之间可能存在转变和重叠现象，而且大多数伴
有轻度的肾小管一间质损害。
3.肝肾阴虚型与MsPGN，湿热内蕴型与IgAN之间呈显著正相关，其余证型与
病理类型之间无显著相关。所以，肝肾阴虚和湿热内蕴型可以分别作为MsPGN、
IgAN诊断的客观指标。由于病例样本数偏少，还有待今后进一步的研究。
4.中医证型总体疗效比较，差异显著。’肾虚血癖、湿热内蕴型的有效率最高，
而脾肾阳虚、气阴两虚型的有效率较差。且肾虚血癖型的复发次数、复发率均最
低，而脾肾阳虚型的复发次数、复发率最高。
5.中药肾康灵对治疗肾虚血癖型FRNS疗效显著，而且能显著降低复发率、减
轻副作用。
Objective: To investigate the relationship between syndrome-type in traditional Chinese medicine(TCM) and renal pathology type in children with frequent relapse nephrotic syndrome(FRNS) , and meanwhile to provide objective indexes and theoretical bases for clinical treatment based on the differentiation of symptoms of TCM, efficacy and prognosis of FRNS, then to increase remission rate , to reduce relapse rate and to lessen side effects.
Methods: Fifty patients with a diagnosis of FRNS were divided into type of Yin deficiency of liver and kidney, type of Yang deficiency of spleen and kidney, type of Wetness-heat accumulating in the interior, type of Kidneyasthenia and blood stasis and type of Qi-Yin deficiency according to symptoms differentiation of TCM. All patients were taken percutaneous renal biopsies. And their renal pathomorphology was observed by light microscope, immunofluorescence and electron microscope. Related experimental indexes were examined in all patients. Therapeutic methods of western medicine integrated TCM were used and curative effects and relapse rate in 0.5,1.0,1.5a were observed .Statistical analysis was performed by SPSS10.05 system software.
Results: In the group the symptoms showed mostly type of Yin deficiency of liver and kidney (16/50) and type of Yang deficiency of spleen and kidney (12/50). And type of Wetness-heat accumulating in the interior, type of Kidneyasthenia and blood stasis and type of Qi-Yin deficiency were minorities. There were 38 children with simple type NS and 12 children with nephritic type NS in the group. But
there was no significant difference between clinical type and syndrome-type in TCM(P>0.05).The most common pathologies were mesangioprolierative glomerulon-ephritis(MsPGN)( 17/50), MsPGN combined focal segmental glomerulosclerosis(FSG S)(13/50), IgA nephropathy(IgAN)( 12/50) and IgM nephropathy (IgMN) (4/50). IgMN, membranous nephropathy (MN), membranoprolierative glomerulonephritis (MPGN) and focal glomerulonephritis(FGN) were minorities. The patients with MsPGN presented mainly type of Yin deficiency of liver and kidney (9/17). The patients with MsPGN+FSGS presented mainly type of Yin deficiency of liver and kidney (4/13), type of Yang deficiency of spleen and kidney (4/13) and type of Kidney asthenia and blood stasis (4/13) respectively. IgAN presented mainly type of Wetness-heat accumulating in the interior (5/12) and IgMN presented mainly type of Yang deficiency of spleen and kidney (2/4). There was a significant positive correlation between MsPGN and type of Yin deficiency of liver and kidney (r=0.938, P<0.05) ,as well as between IgAN and type of Wetness-heat accumulating in the interior (r=0.895, P<0.05). There was no significant correlation among other syndrome-types and pathology types(P>0.05). The difference in therapeutic effects of syndrome-types was significant (P<0.05). Type of Kidneyasthenia and blood stasis and type of Wetness-heat accumulating in the interior had the same efficacy(88.89%), while the efficacy of type of Yang deficiency of spleen and kidney was the least(41.67%). Compared with type of Yang deficiency of spleen and kidney, there was significant difference between type of Yin deficiency of liver and kidney, type of Wetness-heat accumulating in the interior and type of Kidneyasthenia and blood stasis respectively(P<0.05). The relapse rate of type of Kidneyasthenia and blood stasis was 11.11% (in 0.5a),22.22%(in 1.0a) and 33.33%(in 1.5a) respectively, and was the lowest among all syndrome-types. Type of Yang deficiency of spleen and kidney had the highest relapse rate(50% in 0.5a, 66.67% in 1.0a and 83.33% in 1.5a). The two types above mentioned had significant difference in relapse rate in 1.5a(P<0.05).
Conclusion: 1. Type of Yin deficiency of liver and kidney and type of Yang deficiency of spleen
and kidney were the most common types followed by type of Wetness-heat accumulating in the interior, type of Kidneyasthenia and blood stasis and type of Qi-Yin deficiency.
2.
方法：选择50例FRNS患儿，在肾穿前按照中医四诊合参，进行辨证分型。肾穿活检标本分送光镜、免疫荧光、电镜检查，进行病理诊断。在治疗前后和治疗期间进行血、尿常规，血生化，24小时尿蛋白定量和尿沉渣检查，肾功能检查，免疫功能检查等。综合分析中医证型与临床、病理类型的关系。同时采用中西医结合的治疗方法，观察各型疗效以及0.5、1.0、1.5年的复发情况。结果以SPSS10.0统计软件进行分析。
结果：本组中医证型以肝肾阴虚(16／50)、脾肾阳虚(12／50)为主，其次为湿热内蕴(9／50)和肾虚血瘀(9／50)，气阴两虚较少见(4／50)。临床分型中，肾炎型38例，单纯型12例。肾炎型和单纯型中肝肾阴虚、脾肾阳虚、湿热内蕴、肾虚血瘀型均相对较多，而气阴两虚型较少。临床分型与中医证型的分布无显著差别。病理类型以MsPGN(17／50)、MsPGN+FSGS(13／50)和IgAN(12／50)为主，少数为IgMN、MN、MPGN和FGN。MsPGN中以肝肾阴虚多见(9／17)，二者之间呈显著正相关(r=0.938，P＜0.05)；MsPGN+FSGS主要见于肝肾阴虚、脾肾阳虚和肾虚血瘀(各4／13)，证型与病理类型之间无显著相关(r=0.827，P＞0.05)：IgAN中湿热内蕴多见(5／12)，二者呈显著正相关(r=0.895，P＜0.05)。中医证型疗效以肝肾阴虚、湿热内蕴和肾虚血瘀三型有效率较高，均在87.5％以上，且三者间无显著差异(P＞0.05)，而脾肾阳虚和气阴两虚型有效率分别为
福窟中医学脂2口04届描床…硕.于研兑生.学介讼丈
41.67%和50.00%。经统计处理，各型的总体疗效比较差异显著(尸<0.05);脾肾
阳虚型与前三型的疗效比较，差异均显著(尸<0.05);气阴两虚型与其它证型比
较无显著差异(P>.05)。复发情况比较，中医证型间总体复发率比较无显著差
异。肾虚血癖型在随访0.5年、1年和1 .5年的复发次数、复发率均较其它型低，
而脾肾阳虚型的复发次数、复发率较高。其中在1.5年，以上两型复发率比较有
显著差异(P<0.05)。
结论:
1.小儿FRNS中医辨证分型以肝肾阴虚、脾肾阳虚为主，其次为湿热内蕴和肾
虚血癖，气阴两虚较少。
2.小儿FRNs的病理类型以MspGN、MspGN+FSGS、IgAN为多见，IgMN、
MPGN、MN、FGN较少。病理类型之间可能存在转变和重叠现象，而且大多数伴
有轻度的肾小管一间质损害。
3.肝肾阴虚型与MsPGN，湿热内蕴型与IgAN之间呈显著正相关，其余证型与
病理类型之间无显著相关。所以，肝肾阴虚和湿热内蕴型可以分别作为MsPGN、
IgAN诊断的客观指标。由于病例样本数偏少，还有待今后进一步的研究。
4.中医证型总体疗效比较，差异显著。’肾虚血癖、湿热内蕴型的有效率最高，
而脾肾阳虚、气阴两虚型的有效率较差。且肾虚血癖型的复发次数、复发率均最
低，而脾肾阳虚型的复发次数、复发率最高。
5.中药肾康灵对治疗肾虚血癖型FRNS疗效显著，而且能显著降低复发率、减
轻副作用。
Objective: To investigate the relationship between syndrome-type in traditional Chinese medicine(TCM) and renal pathology type in children with frequent relapse nephrotic syndrome(FRNS) , and meanwhile to provide objective indexes and theoretical bases for clinical treatment based on the differentiation of symptoms of TCM, efficacy and prognosis of FRNS, then to increase remission rate , to reduce relapse rate and to lessen side effects.
Methods: Fifty patients with a diagnosis of FRNS were divided into type of Yin deficiency of liver and kidney, type of Yang deficiency of spleen and kidney, type of Wetness-heat accumulating in the interior, type of Kidneyasthenia and blood stasis and type of Qi-Yin deficiency according to symptoms differentiation of TCM. All patients were taken percutaneous renal biopsies. And their renal pathomorphology was observed by light microscope, immunofluorescence and electron microscope. Related experimental indexes were examined in all patients. Therapeutic methods of western medicine integrated TCM were used and curative effects and relapse rate in 0.5,1.0,1.5a were observed .Statistical analysis was performed by SPSS10.05 system software.
Results: In the group the symptoms showed mostly type of Yin deficiency of liver and kidney (16/50) and type of Yang deficiency of spleen and kidney (12/50). And type of Wetness-heat accumulating in the interior, type of Kidneyasthenia and blood stasis and type of Qi-Yin deficiency were minorities. There were 38 children with simple type NS and 12 children with nephritic type NS in the group. But
there was no significant difference between clinical type and syndrome-type in TCM(P>0.05).The most common pathologies were mesangioprolierative glomerulon-ephritis(MsPGN)( 17/50), MsPGN combined focal segmental glomerulosclerosis(FSG S)(13/50), IgA nephropathy(IgAN)( 12/50) and IgM nephropathy (IgMN) (4/50). IgMN, membranous nephropathy (MN), membranoprolierative glomerulonephritis (MPGN) and focal glomerulonephritis(FGN) were minorities. The patients with MsPGN presented mainly type of Yin deficiency of liver and kidney (9/17). The patients with MsPGN+FSGS presented mainly type of Yin deficiency of liver and kidney (4/13), type of Yang deficiency of spleen and kidney (4/13) and type of Kidney asthenia and blood stasis (4/13) respectively. IgAN presented mainly type of Wetness-heat accumulating in the interior (5/12) and IgMN presented mainly type of Yang deficiency of spleen and kidney (2/4). There was a significant positive correlation between MsPGN and type of Yin deficiency of liver and kidney (r=0.938, P<0.05) ,as well as between IgAN and type of Wetness-heat accumulating in the interior (r=0.895, P<0.05). There was no significant correlation among other syndrome-types and pathology types(P>0.05). The difference in therapeutic effects of syndrome-types was significant (P<0.05). Type of Kidneyasthenia and blood stasis and type of Wetness-heat accumulating in the interior had the same efficacy(88.89%), while the efficacy of type of Yang deficiency of spleen and kidney was the least(41.67%). Compared with type of Yang deficiency of spleen and kidney, there was significant difference between type of Yin deficiency of liver and kidney, type of Wetness-heat accumulating in the interior and type of Kidneyasthenia and blood stasis respectively(P<0.05). The relapse rate of type of Kidneyasthenia and blood stasis was 11.11% (in 0.5a),22.22%(in 1.0a) and 33.33%(in 1.5a) respectively, and was the lowest among all syndrome-types. Type of Yang deficiency of spleen and kidney had the highest relapse rate(50% in 0.5a, 66.67% in 1.0a and 83.33% in 1.5a). The two types above mentioned had significant difference in relapse rate in 1.5a(P<0.05).
Conclusion: 1. Type of Yin deficiency of liver and kidney and type of Yang deficiency of spleen
and kidney were the most common types followed by type of Wetness-heat accumulating in the interior, type of Kidneyasthenia and blood stasis and type of Qi-Yin deficiency.
2.
引文
[1]. 陈述枚．小儿肾病综合征的复发问题．中华肾脏病杂志[J]，1993，9(4)：232-234．
[2]. 吴莉．频复发性肾病综合征的病理临床特征．国外医学(儿科分册)[J]，1993，20(6)：317．
[3]. 崔世雄，钱铜荪．儿童特发性肾病综合征治疗进展．中华肾脏病杂志[J]，1994，10(8)：246．
[4]. 牛余宗．频复发性肾病综合征的研究现状．实用儿科临床杂志[J]，1989，4(2)：122-125
[5]. Salwa-Zurawska W,Bortkiewicz E,Wozniak A,etal．PolJ Pathol[J],1999,50(3):163
[6]. Richard J Johnson,John Fechally.Comprehensive Clinical Nephrology[M].First edition,2000．
[7]. 中华医学会儿科学分会肾脏病学组．小儿肾小球疾病的临床分类、诊断及治疗．中华儿科杂志[J]，2001，39(12)：746-749．
[8]. Holdsworth SR, Kitching AR,Tipping. Kidney Int[J], 1999,55(4):1198-1216.
[9]. 甘美莹．小儿原发性肾病综合征与T淋巴细胞亚群的关系．中华肾脏病杂志[J]，1996，12(5)：310．
[10]. 郑健，曾章超，郭云霞．肾康灵冲剂治疗小儿频复发性肾病30例临床观察．中国中西医结合肾病杂志[J]，2002，3(4)：215-217．
[11]. Reccatello D Isidoroc Mazzucco G et al.Kidney Int[J], 1993,43:1150.
[12]. Hinoshita-Foma T, Tomura S, Shiigai T, et al. Nephron[J], 1990,54(2): 122-126.
[13]. 牛余宗，周军平．特发性肾病综合征与细胞因子．国外医学(儿科学分册)[J]，1997，24(6)：318-321．
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[2]. 吴莉．频复发性肾病综合征的病理临床特征．国外医学(儿科分册)[J]，1993，20(6)：317．
[3]. 崔世雄，钱铜荪．儿童特发性肾病综合征治疗进展．中华肾脏病杂志[J]，1994，10(8)：246．
[4]. 牛余宗．频复发性肾病综合征的研究现状．实用儿科临床杂志[J]，1989，4(2)：122-125
[5]. Salwa-Zurawska W,Bortkiewicz E,Wozniak A,etal．PolJ Pathol[J],1999,50(3):163
[6]. Richard J Johnson,John Fechally.Comprehensive Clinical Nephrology[M].First edition,2000．
[7]. 中华医学会儿科学分会肾脏病学组．小儿肾小球疾病的临床分类、诊断及治疗．中华儿科杂志[J]，2001，39(12)：746-749．
[8]. Holdsworth SR, Kitching AR,Tipping. Kidney Int[J], 1999,55(4):1198-1216.
[9]. 甘美莹．小儿原发性肾病综合征与T淋巴细胞亚群的关系．中华肾脏病杂志[J]，1996，12(5)：310．
[10]. 郑健，曾章超，郭云霞．肾康灵冲剂治疗小儿频复发性肾病30例临床观察．中国中西医结合肾病杂志[J]，2002，3(4)：215-217．
[11]. Reccatello D Isidoroc Mazzucco G et al.Kidney Int[J], 1993,43:1150.
[12]. Hinoshita-Foma T, Tomura S, Shiigai T, et al. Nephron[J], 1990,54(2): 122-126.
[13]. 牛余宗，周军平．特发性肾病综合征与细胞因子．国外医学(儿科学分册)[J]，1997，24(6)：318-321．
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