摘要
目的：
探讨在骨质疏松症过程中证型的演变过程；骨质疏松症中医证型与激素、细胞因子、骨钙素、骨密度八个指标的相关性；骨质疏松症中医证型的最佳分类;八个指标中证型判断最佳指标；激素、细胞因子、骨钙素、骨密度之间的相关性。
方法：
把符合骨质疏松症诊断标准的患者按照四个中医证型辨证,由两个副主任医师共同判断证型,收集肾阳虚组21例、脾肾阳虚组20例、肝肾阴虚组21例、气滞血瘀组23例,共85例。清晨空腹抽取血液样本,采用酶联免疫法检测八个指标：E2(雌二醇)、T(睾酮)、IL-6(白介素-6)、TNF-α(肿瘤坏死因子-a)、IGF-1(胰岛素样生长因子-1)、OPG(骨保护素)、BGP(骨钙素)、BMD(骨密度)。DXA测定L2-L4正位骨密度。资料数据进行单因素方差分析、判别分析、聚类分析、因子分析、相关分析、回归分析,使用SPSS17软件统计。
结果：
①按肾阳虚、脾肾阳虚、肝肾阴虚,最终气滞血瘀顺序,E2、T、IGF-1、OPG、BMD下降,IL-6、TNF-α、BGP上升。
②指标E2、IL-6、BGP、BMD在三个虚证与气滞血瘀存在统计学意义；指标TNF-α、IGF-1在肾阳虚和肝肾阴虚与气滞血瘀存在统计学意义；三个虚证之间没有统计学差异。进一步的统计学分析提示在E2、IL-6、TNF-α、IGF-1、OPG、BPG指标中,虚证(脾肾阳虚、肾阳虚、肝肾阴虚)与实证(气滞血瘀)存在显著差异,从数据分析,E2、IL-6、TNF-α、IGF-1、OPG、BPG、BMD在虚证中,均值95%可信空间分别是(68.01-80.75)(pmol/L)、(27.23-42.35)(ng／dl)、(19.91-30.07)(ng／ml)、(35.39-46.55)(μg／L)、(115.39-146.09)(pg／ml)、(2.82-3.26)(μg／L),(0.590-0.618)(g／cm2)；E2、IL-6、TNF-α、IGF-1、OPG、BPG、BMD在实证中,均值95%可信空间是(32.93-54.16)(pmol／L)、(69.09-112.57)(ng／dl)、(35.47-65.80) (ng／ml)、(17.08-32.03)(μg／L)、(82.59-117.81)(pg／ml)、(3.75-4.86)(μg／L)、(0.425-0.466)(g／cm2)。
③对四个证型判别分析,肾阳虚的正确率是57.1%,脾肾阳虚的正确率是50%,肝肾阴虚的正确率是23.8%,气滞血瘀的正确率是95.7%；虚证与实证进行判别分析,虚证的正确率是93.5%,实证的正确率是95.7%。
④E2、IL-6、TNF-α、BGP、BMD在四个证型中分别聚类出虚证和实证,而T、IGF-1和OPG指标不能聚类出虚证和实证,八个指标聚类出五类：促进成骨细胞和抑制破骨细胞的E2、OPG、IGF-1,雄性激素T,促进破骨细胞活性的细胞因子IL-6、TNF-α,成骨细胞产生的代表骨转换的BGP,骨矿含量BMD。
⑤因子分析可以把证型继续分类为三个类型,以不同指标为重点,肾阳虚主因子1在E2、IL-6、IGF-1,主因子2在TNF-α、BGP,主因子3在T、OPG指标上有较大的载荷；脾肾阳虚主因子1在E2、IL-6、IGF-1、OPG,主因子2在TNF-α、BGP,主因子3在T、IGF-1指标上有较大的载荷；肝肾阴虚主因子1在E2、OPG、BGP,主因子2在IL-6、TNF-α、IGF-1,主因子3在T指标上有较大的载荷；气滞血瘀主因子分析：软件提供前3公因子作为主因子,因为其累积贡献率为0.73,主因子1在TNF-α、IGF-1、BGP,主因子2在E2、OPG,主因子3在T、IL-6指标上有较大的载荷。
⑥指标的相关性：E2与T、IGF-1、OPG正相关；E2与IL-6部分负相关；E2与TNF-α、BGP负相关；T与IGF-1正相关；T与BGP负相关；IL-6与TNF-α、BGP部分正相关；IL-6与IGF-1、OPG部分负相关；TNF-α与IGF-1部分负相关;TNF-α与BGP部分正相关；IGF-1与OPG部分正相关；IGF-1与BGP部分负相关；OPG与BGP部分负相关；BMD与E2、IGF-1部分正相关；BMD与IL-6、TNF-α、BGP部分负相关,相关具有显著统计学意义。
结论：
①随着骨质疏松症由轻到重,证型从肾阳虚,继而脾肾阳虚,肝肾阴虚,最终气滞血瘀。
②八个指标中E2、IL-6、TNF-α、IGF-1、BPG能分辨虚证和实证证型,E2在268.01-80.75 (pmol/L), IL-6在27.23-42.35 (ng/dl), TNF-α在19.91-30.07 (ng/ml), IGF-1在35.39-46.55 (μg/L), BPG在2.82-3.26 (μg/L), BMD在0.590-0.618 (g/cm2)范围可以认为是虚证；E2在32.93-54.16 (pmol/L), IL-6在69.09-112.57 (ng/dl), TNF-α在35.47-65.80 (ng/ml), IGF-1在17.08-32.03 (μg/L), BPG在3.75-4.86 (μg/L), BMD在0.425-0.466 (g/cm2)范围可以认为是实证。
③骨质疏松症中医证型最佳分为虚证和实证。
④E2、IL-6、TNF-α、BGP、BMD最佳区分虚证和实证。
⑤每个证型有三种针对不同靶点(指标)的治疗方法,肾阳虚治疗可分三类,一类是针对E2、IL-6、IGF-1,二类是针对TNF-α、BGP,三类是针对T、OPG;脾肾阳虚治疗分三类,一类是针对E2、IL-6、IGF-1、OPG,二类是针对TNF-α、BGP,三类是针对T、IGF-1指标；肝肾阴虚治疗分三类,一类针对E2、OPG、BGP,二类是针对IL-6、TNF-α、IGF-1,三类是针对T；气滞血瘀治疗分三类,一类是针对TNF-α、IGF-1BGP,二类是针对E2、OPG,三类是针对T、IL-6。
⑥八个指标可分五类：促进成骨细胞和抑制破骨细胞的E2,、OPG、IGF-1;雄性激素T；促进破骨细胞活性的细胞因子IL-6、TNF-α;成骨细胞产生的BGP；骨矿含量BMD。八个指标相关性：E2与T、IGF-1、OPG正相关；E2与IL-6部分负相关；E2与TNF-α、BGP负相关；T与IGF-1正相关；T与BGP负相关；IL-6与TNF-α、BGP部分正相关；IL-6与IGF-1、OPG部分负相关；TNF-α与IGF-1部分负相关；TNF-α与BGP部分正相关；IGF-1与OPG部分正相关；IGF-1与BGP部分负相关；OPG与BGP部分负相关；BMD与E2、IGF-1部分正相关；BMD与IL-6、TNF-α、BGP部分负相关,相关具有显著统计学意义。
Objective
To explore the change of the TCM syndromes during the development of Osteoporosis, To study the correlation between four TCM syndromes and Cytokines/Hormones/BGP/BMD in Osteoporosis, To study the best classification of TCM syndromes, To filter the best indexs of judgement methods of TCM syndromes, To explore The correlation between inter-Cytokines/Hormones/BGP/ BMD.
Methods
85 Cases of postmenopausal women of Osteoporosis were collected and divided into four groups according the judgement of four TCM syndromes respectively. There are 21examples in Kidney yang-deficiency;21examples in Liver and kidney yin-deficency;20examples in Spleen and kidney yang-deficency and 23examples in Qi-blood stasis. each case have their blood sampled in the morning before breakfast, Examine Estradiol (E2)/Testosterone (T) /IL-6/IGF-1/TNF-α/OPG and BGP in serum. And detect their BMD by normotopia of L2-L4 by DXA. The data analysises use one-way ANOVA/Hierarchical Cluster/Discriminant/Factor/Regression.
Result
①From kidney yang-deficiency/Spleen and kidney yang-deficency/Liver and kidney yin-deficency to qi-blood stasis, Index E2/T/IGF-1/OPG/BMD is decline and IL-6/TNF-α/BGP is ascend.
②There is statistically significant differences between kidney yang-deficiency/Spleen-kidney yang-deficency/Liver-kidney yin-deficency and qi-blood stasis in E2/IL-6/BGP/BMD, There is statistically significant differences between kidney yang-deficiency/liver and kidney yin-deficiency and qi-blood stasis in IGF-1/TNF-α, There is no statistically significant differences between kidney yang-deficiency/Spleen and kidney yang-deficency /Liver and kidney yin-deficency in eight index;Mean of 95% believable space of E2/IL-6/TNF-α/IGF-1/OPG/BPG/BMD in deficiency syndrome is (68.01-80.75 ) (pmol/L)/(27.23-42.35) (ng/dl)/(19.91-30.07) (ng/ml)/(35.39-46.55) (μg/L)/(115.39-146.09) (pg/ml)/(2.82-3.26) (ug/L)/ (0.590-0.618) (g/cm2) range; Mean of 95% believable space of E2/IL-6/TNF-α/IGF-1/OPG/BPG/BMD in qi-blood stasis is (32.93-54.16)(pmol/L )、(69.09-112.57) (ng/dl)/(35.47-65.80) (ng/ml)/(17.08-32.03) (μg/L)/(82.59-117.81) (pg/ml)/(3.75-4.86) (μg/L)/(0.425-0.466 ) (g/cm2) range.
③Discriminant of four TCM syndromes, The precision rate of judgement of Kidney yang-deficiency is 57.1%, Spleen and kidney yang-deficency is 50% and Liver and kidney yin-deficency is 23.8%, qi-blood stasis is 95.7%, But in Discriminant of tow TCM syndromes, the precision rate of judgement of deficiency syndrome (Kidney yang-deficiency/Spleen and kidney yang-deficency/Liver and kidney yin-deficency) is 93.5%, Qi-blood stasis is 95.7%.
④Cluster analysises show that E2/IL-6/TNF-α/BGP/BMD in every syndrome can cluster into two syndromes of deficiency syndrome and blood stasis, The other indexs can not.
⑤Factor analysises points out that each of four TCM syndromes can be divided into three main factors by defferent indexs. kidney yang-deficiency s main factorl in E2/IL-6/IGF-1, main factor2 in TNF-α/BGP, main factor3 in T/OPG have larger loads; Spleen and kidney yang-deficency's main factorl in E2/IL-6/IGF-1/OPG, main factor2 in TNF-α/BGP, main factor3 in T/IGF-1 have larger loads; Liver and kidney yin-deficency's main factorl in E2/OPG/BGP , main factor2 in IL-6/TNF-α/IGF-1, main factor3 in T have larger loads; qi-blood stasis's main factorl in TNF-α/IGF-1/BGP, main factor2 in E2/OPG , main factor3 in T/IL-6 have larger loads.
⑥Eight indicators cluster five kinds:The first kind is E2/OPG/IGF-1 that is to promote the osteoblast and inhibit osteoclast,The sencond kind is androgen (T), The third kind is cytokines IL-6/TNF-αthat is to promote osteoclast activity, The fourth kind is BGP that is produced by osteoblast and represent bone metabolism, The fifth is BMD that is reflect bone mineral content .Regression analysises show that The correlation between E2 and T/IGF-1/OPG is significant positive, The correlation between E2 and IL-6 is significant part negative, the correlation between E2 and TNF-α/BGP is significant negative, The correlation between T and IGF-1 is significant positive, T and BGP is significant negative, the correlation between IL-6 and TNF-α/BGP is significant part positive,the correlation between IL-6 and IGF-1/OPG is significant part negative, the correlation between TNF-αand IGF-1 is part negative, the correlation between TNF-a and BGP is significant part positive, the correlation between IGF-1 and OPG is significant part positive, the correlation between IGF-1 and BGP is part significant negative, the correlation between OPG and BGP is part significant negative, the correlation between BMD and E2/IGF-1 is part significant positive, the correlation between BMD and IL-6/TNF-α/BGP is part significant negative.
Conclusion
①With the Osteoprosis become more serious,The order of TCM syndrome is from kidney yang-deficiency to Spleen and kidney yang-deficency to Liver and kidney yin-deficency to qi-blood stasis.
②In eight indexs, E2/IL-6/TNF-α/IGF-1/BPG can distinguish deficiency syndrome from qi-blood stasis,It can be thinked deficiency syndrome as E2 in 2 68.01-80.75 (pmol/L), IL-6 in 27.23-42.35 (ng/dl), TNF-αin 19.91-30.07 (ng/ml), IGF-1 in 35.39-46.55 (μg/L), OPG in 115.39-146.09 ( pg/ml), BPG in 2.82-3.26 (μg/L), BMD in 0.590-0.618 (g/cm2) range, It can be thinked qi-blood stasis as E2 in 32.93-54.16 (pmol/L), IL-6 in 69.09-112.57 (ng/dl), TNF-αin 35.47-65.80 (ng/ml), IGF-1 in 17.08-32.03 (μg/L), OPG in 82.59-117.81) (pg/ml), BPG in 3.75-4.86 (μg /L), BMD in 0.425-0.466 (g/cm2) range.
③The best types of TCM syndromes in Osteoporosis is deficiency and qi-blood stasis, If the deficiency syndrome type Continually, It is easier to produce wrong result.
④E2/IL-6/TNF-α/BGP is the best indexs to distinguish deficiency syndrome from qi-blood stasis.
⑤Factor analysises make more methods of treatments of Osteoporosis. kidney yang-deficiency treatment have three kinds, The first kind aim at E2/IL-6/IGF-1, The second aim at TNF-α/BGP, The third aim at T/OPG; Spleen and kidney yang-deficency treatment have three kinds, The first kind aim at E2/IL-6/IGF-1/OPG, The second aim at TNF-α/BGP, The third aim at T/IGF-1; Liver and kidney yin-deficency treatment have three kinds, The first kind aim at E2/OPG/BGP, The second aim at IL-6/TNF-α/IGF-1, The third aim at T; Qi-blood stasis treatment have three kinds, The first kind aim at TNF-α/IGF-1/BGP, The second aim at E2/OPG, The third aim at T/IL-6.
⑥Eight indexs cluster four kinds:The first kind is E2/OPG/IGF-1 that is to promote the osteoblast and inhibit osteoclast, The sencond kind is androgen (T), The third kind is cytokines IL-6/TNF-αthat is to promote osteoclast activity, The fourth kind is BGP that is produced by osteoblast and represent bone metabolism. Regression analysises show that The correlation between E2 and T/IGF-1/OPG is significant positive, The correlation between E2 and IL-6 is significant part negative, the correlation between E2 and TNF-α/BGP is significant negative, The correlation between T and IGF-1 is significant positive,T and BGP is significant negative, the correlation between IL-6 and TNF-α/BGP is part significant positive, the correlation between IL-6 and IGF-1/OPG is part significant negative, the correlation between TNF-αand IGF-1 is part significant negative, the correlation between TNF-αand BGP is part significant positive, the correlation between IGF-1 and OPG is part significant positive, the correlation between IGF-1 and BGP is part significant negative, the correlation between OPG and BGP is part significant negative. the correlation between BMD and E2/IGF-1 is part significant positive, the correlation between BMD and IL-6/TNF-α/BGP is part significant negative.
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