摘要
目的：分析原发性高血压患者不同中医体质类型间早期肾损害指标的差异性及相关性,探讨影响高血压早期肾损害的因素,为早期预防、诊断高血压肾损害提供依据,同时为中医药个体化治疗原发性高血压早期肾损害寻求客观依据和探索新的思路。
方法：在东直门医院病房及门诊筛选原发性高血压患者,根据相应的纳入、排除标准进行病例收集,签署知情同意书,采集患者的一般资料及高血压相关情况,测量血压,填写中医体质量表并根据《中医体质分类判定标准》对其进行中医体质分类,留取患者晨起尿液标本送至东直门医院检验科检测早期肾病尿液蛋白检查四项(MALB、TRF、β2-MG、 α1-MG),晨起空腹抽取静脉血送至东直门医院检验科生化室检测血糖、胰岛素、肌酐、尿素氮、甘油三酯、胆固醇。最后对采集的数据资料进行统计分析。
结果：
1基本资料：本研究有450例原发性高血压患者入组,年龄18～80岁,平均年龄68.42±14.78岁。其中男性240例(53.3%),平均年龄66.86±16.39岁；女性210例(46.7%),平均年龄70.20±12.48岁。高血压病程0.1～60年,平均病程16.60±14.22年。文化程度以小学居多,初中、高中次之。女性平均年龄要高于男性；女性平均身高比男性低11.73cm；男性BMI略高于女性,但差异无统计学意义。男性吸烟、饮酒率均明显高于女性。
2BMI与空腹血糖(FBG)、空腹胰岛素(FINS)、胰岛素抵抗指数(HOMA-IR)之间的相关性。BMI≥26组的FINS、HOMA-IR要高于BMI<24组和24≤BMI<26组的。BMI<24组与24≤BMI<26组之间FINS、HOMA-IR差异无统计学意义。三组间总体FBG差异无统计学意义。
3降压药服用及血压控制情况。服用降压药者354例(78.7%),未服用降压药者96例(21.3%)；服药患者中规律服药者321例,占90.68%,未规律服药者33例,占9.32%。服用降压药患者的血压达标率明显高于未服用降压药患者的血压达标率。规律服用降压药患者的血压达标率明显高于不规律服用降压药患者的血压达标率。所有服用降压药中,ARB类120次,ACEI类27次,CCB类252次,β受体阻滞剂78次,利尿剂69次。CCB类降压药服用频次最高,ARB类次之。CCB类降压药使用率明显高于其他类。CCB类降压药与血压达标率呈显著正相关,即：CCB类降压药仍是控制血压达标的第一选择。
4高血压中医体质情况。450例原发性高血压患者中,平和质有48例(10.7%),单一偏颇体质中以阴虚质55例最多(12.2%),瘀血质及湿热质次之,各有40例(8.9%),特禀质仅有3例(0.7%)。兼夹体质以两种兼夹体质最多,达76例(16.9%),是分类体质中最多的类型。三种兼夹体质达到43例(9.6%),六种兼夹体质仅有2例(0.4%)。各偏颇体质出现频次,由多到少依次为气虚质,瘀血质,阴虚质,痰湿质,湿热质,气郁质,阳虚质,特禀质。而男女体质构成比有差别。
5各种中医体质与各因素之间的相关性。平和质与冠心病呈负相关,与血压控制情况呈正相关。气虚质与冠心病呈正相关。阳虚质与年龄、吸烟、高血压家族史呈正相关。阴虚质与脑血管呈正相关。瘀血质与体重指数(BMI)、吸烟呈负相关；与饮酒、冠心病、脑血管病呈正相关。痰湿质与吸烟、冠心病、脑血管病呈正相关；与血压控制情况呈负相关。湿热质与教育程度、BMI、吸烟呈正相关。气郁质与脂代谢异常、血压控制情况呈负相关、与服用降压药呈正相关。
6不同中医体质间胰岛素抵抗指数(HOMA-IR)差异性比较。159例患者测FBG、FINS,经公式算出HOMA-IR。不同体质间HOMA-IR总体差异具有统计学意义。其中单纯阳虚质HOMA-IR显著高于单纯痰湿质及单纯湿热质者。
7各偏颇体质(特禀质除外)与平和质之间早期肾损害指标差异性比较。早期肾损害四项指标与性别无关。四项指标在不同中医体质类型组间总体差异均有统计学意义。对四项指标进行各偏颇体质(特禀质除外)与平和质的比较。各偏颇体质的MALB均高于平和质,差异均具有统计学意义,尤以气虚质最高。各偏颇体质的β2-MG均高于平和质,但只有湿热质与平和质比较差异具有统计学意义,余无统计学意义。各偏颇体质的TRF均高于平和质,只有瘀血质与平和质差异无统计学意义,余差异均具有统计学意义,尤以痰湿质最高。各偏颇体质的α1,-MG均高于平和质,只有阳虚质、阴虚质与平和质差异无统计学意义,余差异均具有统计学意义,尤以气郁质最高。
8早期肾损害指标与各因素回归分析。MALB与文化程度呈正相关,与脂代谢异常、血压控制情况呈负相关。β2-MG与BMI呈正相关。TRF与文化程度、服用降压药呈正相关,与脂代谢异常、血压控制情况呈负相关。α1-MG与吸烟、夜尿次数呈正相关,与服用降压药、血压控制情况呈负相关。
9早期肾损害指标与服用降压药类别之间的相关性。MALB与是否服用五类降压药均无相关性。β2-MG升高与服用ACEI类降压药呈负相关,即ACEI类降压药可以降低β2-MG。TRF升高与ARB类呈负相关,即ARB类降压药可以降低TRF;TRF升高与CCB类呈正相关,即CCB类降压药使TRF升高。α1-MG升高与ARB类、CCB类呈负相关,即ARB类、CCB类降压药可以降低α1-MG。
10早期肾损害指标与HOMA-IR回归分析,结果四项指标与HOMA-IR之间均未见其相关性。
结论：
1原发性高血压患者中医体质以阴虚质最多,偏颇体质频次以气虚质最为广泛。男女体质构成比不一致。
2各偏颇体质(特禀质除外)与平和质早期肾损害指标相比,各偏颇体质的高血压早期肾损害程度要比平和质的严重,痰湿质、湿热质、气虚质尤其明显。其中气虚质、痰湿质高血压患者肾小球早期损害最为突出,而湿热质高血压患者最易损伤肾小管。
3ACEI类降压药可以降低β2-MG;ARB类降压药可以降低TRF;ARB类、CCB类降压药可以降低α1-MG;CCB类降压药可使TRF升高。
4单纯阳虚质HOMA-IR要高于单纯痰湿质及单纯湿热质者。早期肾损害四项指标与HOMA-IR之间未见其相关性。
Purposes:We was to analyze the difference and correlation about the indexes of early renal damage between the patients with essential hypertension (EH) in different TCM constitutional types, explore the influencing factors of early renal damage caused by EH, provide the basis for prevention and diagnosis of early renal damage caused by EH, seek objective basis and explore new thoughts for the treatment of it by individualization of TCM at the same time.
Methods:We screened patients with EH according to the relevant inclusion and exclusion criteria in the ward and outpatient of Dongzhimen Hospital, signed informed consent form, gathered the general information and condition relevant to hypertension, measured blood pressure (BP), filled the form of TCM constitution and then classified the type of him according to 《The classified standard of TCM constitution》.His morning urine specimens was sent to the clinical laboratory of Dongzhimen Hospi tal where the four urinary protein indexes (MALB、 TRF、β2-MG、α1-MG)with early nephropathy were tested, at the same time the morning fasting venous blood was tested of blood glucose, insulin, creatinine,urea nitrogen, triglyceride,cholesterol at the clinical biochemical laboratory. Finally,we analyzed the statistics about all the collected data.
Results:
1Basic Information:450cases with EH were collected into the study, ages18to80years, mean age68.42±14.78years. There were240cases (53.3%) of men whose mean age was66.86±16.39years old and210cases (46.7%) of women whose mean age was70.20±12.48years old. The course of hypertension was from0.1to60years averaged16.60±14.22years. The case from primary school was the most, junior and senior high school in turn. Women were older than men on average age. Women were lower11.73cm than men on average height. The BMI of men was slightly bigger than women, but there was no statistically significant dif-ference. Smoking and drinking rates of men were significantly higher than women.
2The correlation between BMI and fasting blood glucose (FBG), fasting insulin (FINS), insulin resistance index (HOMA-IR). FINS and HOMA-IR of group BMI>26were all higher than the groups of BMI<24and24≤BMI<26. There were no statistically significant differences in FINS and HOMA-IR between the groups of BMI<24and24≤BMI<26. There was no statistically significant overall difference between the three groups in FBG.
3Condition about antihypertensive drugs took and BP.354cases (78.7%) were taking antihypertensive drugs and96cases (21.3%) were not. There were321cases (90.68%) taking antihypertensive drugs regularly, but33cases (9.32%) er-ratically. The rate of reaching the standard in the patients of taking an- tihypertensive drugs was significantly higher than the patients who were not taking antihypertensive drugs. The rate of BP reaching the standard in the patients of taking antihypertensive drugs regularly was significantly higher than the patients who were taking ant ihypertens ive drugs erratically. There were120times of ARB classes,27times of ACE I classes,252times of CCB classes,78times of β-blockers,69t imes of diuretics in all ant ihypertens ive drugs took. The taking frequency of CCB classes was highest and ARB classes secondly. The taking rate of CCB classes was significantly higher than other four classes. There was significantly positively correlation in taking antihypertensive drugs of CCB classes and BP reaching the standard, so they were still the first choices to control BP.
4Condition of TCM constitution in hypertension. There were48cases of Normal-constitution in450patients with EH, Yin-deficiency constitution which had55cases(12.2%) was the most in the single lopsided constitutions, Blood stasis and Damp-heat constitutions were the second both40cases (8.9%) Special-constitution had only3cases (0.7%).2types combined constitutions which had76cases (16.9%) was the most type in combined constitutions.3types combined constitutions had43cases (9.6%) and6types combined constitutions had only2(0.4%).The turn of appearing frequency from more to less in lopsided constitutions was:Qi-deficiency constitution, Blood stasis constitution, Yin-deficiency constitution, Phlegm-dampness constitution, Damp-heat con-stitution, Qi-stagnation constitution, Yang-deficiency constitution and Special-constitution. There was difference between men and women in the composing of TCM constitution.
5The correlations between all kinds of TCM constitutions and various factors. Normal-constitution had a negative correlation wi th coronary heart disease (CHD), positive correlation with the condition of BP control. Qi-deficiency con-stitution had a positive correlation with CHD. Yang-deficiency constitution had negative correlations with age, smoking and family history of hypertension. Yin-deficiency constitution had a positive correlation with cerebrovascular disease. Blood stasis constitution had negative correlations with body mass index (BMI) and smoking; positive correlations with drinking, CHD and cere-brovascular disease. Phlegm-dampness constitution had positive correlations with smoking, CHD and cerebrovascular disease; negative correlation with condition of BP control. Damp-heat constitution had positive correlations with education level, BMI, smoking. Qi-stagnation constitution had negative cor-relations with abnormal lipid metabolism and condition of BP control, positive correlation with taking antihypertensive drugs.
6The difference comparisons between different TCM const i tut ions in HOMA-IR.159patients' FBG, FINS were tested and then HOMA-IR were calculated by formula. There was statistically significant overall difference between different TCM con-stitutions in HOMA-IR. The HOMA-IR of pure Yang-deficiency constitution was significantly higher than pure Phlegm-dampness constitution and pure Damp-heat constitution hot.
7The difference comparisons between each lopsided constitutions (Spe-cial-constitution excepted) and Normal-constitution in the four indexes of early renal damage. The all four indexes of early renal damage had no correlation with gender, but had significant overall differences between different types of TCM constitutions. Each lopsided constitutions (Special-constitution ex-cepted) compared with Normal-constitution in the four indexes. The MALB of all lopsided constitutions were higher than Normal-constitution and had statistical differences, especially Qi-deficiency constitution's was the highest. The β2-MG of all lops ided constitutions were higher than Normal-constitution, but only the Damp-heat constitution had a statistical difference compared with Nor-mal-constitution, and the other lopsided constitutions had no statistical difference with Normal-constitution. The TRF of all lopsided constitutions were higher than Normal-constitution and had statistical differences except Blood stasis constitution, especially Phlegm-dampness constitution's was the highest. The α1-MG of all lopsided constitutions were higher than Normal-constitution and had statistical differences except Yang-deficiency constitution and Yin-deficiency constitution, especially Qi-stagnation constitution's was the highest.
8Logistic regression between the four indexes of early renal damage and various factors. MALB had a positive correlation with education level; negative correlations with abnormal lipid metabolism and condition of BP control. β2-MG had a positive correlation with BMI. TRF had posi tive correlations with education level and taking antihypertensive drugs, negative correlations with abnormal lipid metabolism and condition of BP control. α1-MG had positive correlations with smoking and the times of night urination, negative correlations with taking antihypertensive drugs and condition of BP control.
9The correlations between four indexes of early renal damage and the five types of taking antihypertensive drugs. MALB had no correlation with taking any five antihypertensive drugs. The rise of β2-MG had a negative correlation with taking ACEI drugs, that was to say ACEI drugs can reduce β2-MG. The rise of TRF had a negative correlation with taking ARB drugs, that was to say ARB drugs can reduce TRF. The rise of TRF had a positive taking CCB drugs,that was to say CCB drugs can increase TRF. The rise of α1-MG had negative correlations with taking ARB and CCB drugs, that were to say ARB and CCB drugs can reduce α1-MG.10Regression analyses between the four indexes of early renal damage and HOMA-IR. There was no correlation between the four indexes of early renal damage and HOMA-IR.
Conclusions:
1Yin-deficiency constitution is the most in the types of TCM constitutions in the patients with EH, but the frequency of Qi-deficiency constitution is the most in the8lopsided constitutions. There is difference between men and women in the composing of TCM constitution.
2The difference comparisons between each lopsided constitutions (Spe-cial-constitution excepted) and Normal-constitution in the four indexes of early renal damage. The degree of early renal damage caused by hypertension in8lopsided constitut ions are more serious than Normal-constitution, especially in Phlegm-dampness constitution. Damp-heat constitution and Qi-deficiency constitution. The damage of glomerulus is most special in Qi-deficiency constitution and Phlegm-dampness constitution, however the kidney tubules are more easily damaged by hypertension in Damp-heat constitution.
3ACE I drugs can reduce (β2-MG; ARB drugs can reduce TRF; ARB and CCB drugs can reduce α1-MG. CCB drugs can increase TRF.
4The HOMA-IR of pure Yang-deficiency constitution is higher than pure Phlegm-dampness constitution and pure Damp-heat constitution hot. There is no correlation between the four indexes of early renal damage and HOMA-IR.
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