摘要
[背景／目的]本文分为3部分。首先,我们综述了慢性肾脏病(Chronic kidney disease, CKD)5期的临床特征和影响因素。CKD5期就是指传统的慢性肾功能不全(Chronic renal failure, CRF)肾衰竭期和尿毒症期。中医学者认为,根据CKD5期患者主要临床表现和病理演变过程,一般可归属于中医学“水肿”、“癃闭”、“关格”、“肾劳”、“肾风”、“腰痛”、“溺毒”等病证的范畴。与CKD5期患者病情进展相关的影响因素包括血清肌酐、血清尿素氮、残余肾功能、蛋白尿、高血压、贫血、血脂异常、高尿酸血症以及水、电解质代谢紊乱等。其次,我们总结了中药延缓CKD5期肾功能减退的临床疗效和作用机制。国内中医学者和一些日本汉方学者认为,中药(汉方)参与的中西医结合疗法可以有效地延缓CKD5期患者进入透析治疗的时间,还可以减少透析患者相关的并发症。其治疗方法包括中药复方口服、中药保留灌肠、中药复方口服联合中药保留灌肠以及结肠透析联合中药保留灌肠等。中药延缓CKD5期肾功能减退的机制主要是指中药改善肾小球硬化和肾间质纤维化的作用,譬如,通过影响肾小球血流动力,减轻足细胞损伤,抑制转化生长因子-β表达,调整脂质代谢紊乱来改善肾小球硬化；通过减轻巨噬细胞浸润,抑制肾小管上皮细胞转分化,降低尿蛋白毒性来改善肾间质纤维化等。另外,对于晚期CKD5期患者所出现的钙/磷代谢失衡、微炎症状态以及尿毒症毒素蓄积,中药也有一定的改善作用。最后,作为本文的重点,我们报道了CKD5期中医证候特征及其与实验室指标相互关系的分析。也就是分析CKD5期患者的中医证候特征,阐明其中医证候特征与常规实验室指标之间的相互关系,为CKD中医证候客观化研究提供依据。[方法]采用传统流行病学回顾性调查方法,收集100例CKD5期患者中医证候和实验室指标等相关资料,分析中医证型与相关实验室指标的关系,其中,实验室指标包括血清肌酐(Serum creatinine, Scr)、血清尿素氮(Blood urea nitrogen, BUN)、残余肾功能(Residualrenal function, RRF).尿量(Urine volume, UV).血红蛋白(Hemoglobinassay, Hb).红细胞计数(Red blood cell count, RBC).血清总胆固醇(Total cholesterol, TC)、血清甘油三酯(Triglyceride, TG).血清低密度脂蛋白胆固醇(Low density lipoprotein cholesterol, LDL-C).血清高密度脂蛋白胆固醇(High density lipoprotein cholesterol, HDL-C).血清白蛋白(Serum albumin, Alb).血尿酸(Serum uric acid, SUA)、血钾(Potassium, K+)、血钠(Sodium, Na+)、血钙(Calcium, Ca2+)、血磷(Phosphorus, P3+)等。[结果]在47例CKD5期非血液透析患者中,主要的中医症状为“倦怠乏力、腰膝酸软、口燥咽干、发脱齿摇、畏寒喜暖、浮肿难消、纳呆腹胀、头晕耳鸣、恶心呕吐、唇甲紫暗”等,其中,(脾肾)气阴两虚证者最多,占57.4%。在53例CKD5期血液透析患者中,主要的中医症状为“纳差少尿、畏寒肢冷、脘冷喜热饮、便干尿少、口燥咽干、面色晄白或黧黑、头晕耳鸣、发脱齿摇”等,其中,脾肾阳虚证者最多,占62.3%；在CKD5期血液透析患者中,脾肾阳虚证者RRP、UV异常降低,TC、LDL-C、P3+、BUN. Scr、SUA异常升高,与非脾肾阳虚证者相比,2组间差异均有统计学意义(P<0.05)。[结论]在47例CKD5期非血液透析患者中,中医证候特征是气阴两虚；在53例CKD5期血液透析患者中,中医证候特征是脾肾阳虚。无论是否接受血液透析,CKD5期患者的基本病机是脾肾两虚。对于CKD5期血液透析患者,可以将降低的实验室数据‘'RRF、UV",以及升高的实验室数据"TC、LDL-C.P3+”作为其脾肾阳虚证候诊断的相关参考指标。对于CKD5期非血液透析患者,没有发现中医证候特征与其实验室指标间的相互关系。
[Background/Aim] In this article, the first, we reviewed the clinical characteristics and the related factors in patients with stage 5 chronic kidney disease (CKD). Here, the patients with stage 5 CKD mean the person with chronic renal failure (CRF) at renal failure or uremia stage. On the basis of clinical features and pathological mechanisms of stage 5 CKD, these patients were diagnosed the illness in Traditional Chinese Medicine (TCM) as "edema" or "retention of urine" or " obstruction and rejection" or "kidney consumption" or "wind due to dysfunction of kidney" or "lumbago" or "turbid dampness-toxicity". The related factors of stage 5 CKD include serum creatinine (Scr), blood urea nitrogen (BUN), residual renal function (RRF), proteinuria, hypertension, anemia, dyslipidemia, hyperuricemia, and water and electrolyte metabolism disorder. The second, we discussed the effects and mechanisms of Chinese herbal medicine for delaying the progression of renal dysfunction in stage 5 CKD patients. Initial time of dialysis and dialysis-related complications in the patients with stage 5 CKD were ameliorated through the treatment with combination of traditional Chinese and Western medicine, including oral administration or coloclysis of Chinese herbal medicine, oral administration combined with coloclysis of Chinese herbal medicine, and colonic dialysis combined with coloclysis of Chinese herbal medicine. Chinese herbal medicine ameliorated renal dysfunction including glomerulosclerosis and renal interstitial fibrosis by improving glomerular hemodynamics turbulence, podocyte injury, transforming growth factor (TGF)-βover-expression, hyperlipidemia, macrophage infiltration, tubular epithelial myofibroblast transdifferentiation, and nephrotoxicity of proteinuria. And that, it improved metabolic dysequilibrium of calcium and phosphonium, microinflammatory state, and uremic toxins in patients with uremia. The third, as a focal point in this article, it is reported that analysis of characteristic of TCM symptom and its relationship with laboratory parameter in patients with stage 5 CKD. The aim of this study is to anlyze the characteristic of TCM syndrome and its dependence with laboratory indexe in stage 5 CKD patients, for the sake of providing a basis for clarifying the rules of TCM syndrome differentiation in CKD. [Methods] The traditional retrospective method commonly used in epidemiological investigation was established. Data from 100 patients with stage 5 CKD were collected, and analysis between TCM symptoms and laboratory parameters, such as Scr, BUN, RRF, urine volume (UV), hemoglobinassay (Hb), red blood cell count (RBC), total cholesterol (TC), triglyceride (TG), low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), serum albumin (Alb), serum uric acid (SUA), potassium (K+), sodium (Na+), calcium (Ca2+), and phosphonium (P3+). [Results] In 47 non-hemodialysis patients with stage 5 CKD, the TCM symptoms included fatigue, aching loins and knees, dry mouth and throat, trichomadesis and loose teeth, aversion to cold and favor to warm, edema, indigestion and bloating, dizziness and tinnitus, dizziness and tinnitus, nausea and vomiting, dark lips and fingernail, etc. In which, the highest rate of the patients with deficiency of both qi and yin type was 57.4%. In 53 hemodialysis patients with stage 5 CKD, the TCM symptoms included anorexia and oliguria, aversion to cold, abdominal cold and liking hot drinks, constipation, dry mouth and throat, white and black face, dizziness and tinnitus, trichomadesis and loose teeth, etc. In which, the highest rate of the patients with Pi-Shen yang deficiency type was 62.3%. During the follow-up period, the level of RRF and UV was significantly lower and the level of TC, LDL-C, P3+, BUN, Scr, and SUA was higher in stage 5 CKD hemodialysis patients with Pi-Shen yang deficiency type compared with the patients with other TCM symptom type (P<0.05). [Conclusion] For 47 non-hemodialysis patients with stage 5 CKD, deficiency of both qi and yin is the major clinical characteristic of TCM, however, for 53 hemodialysis patients, it is Pi-Shen yang deficiency type. The level of RRF, UV, TC, LDL-C, and P3+, which is related to Pi-Shen yang deficiency type, could be taken as one of the relative factors for the syndrome type. Besides, deficiency of both Pi and Shen is the basic mechanism of disease in stage 5 CKD patients. For non-hemodialysis patients with stage 5 CKD, there is no relationship between TCM syndromes and laboratory parameters.
引文
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