【作者】 王宇晖；

【导师】 王永钧；

【作者基本信息】 浙江中医药大学 ， 中西医结合临床， 2012， 博士

【摘要】 目的：探讨慢性肾小球肾炎、慢性肾脏病(CKD)3期肾络瘀痹证的中医证候特点、临床病理表现,以及加味积雪草方、贝那普利及其联用在CKD3期的疗效分析。方法：1.采用前瞻性、双盲双模拟、随机对照的临床研究方法。2.研究对象：西医诊断为慢性肾小球肾炎(CKD3期)、中医辨证为肾络瘀痹证(瘀痹证)。合并证有肾气阴(血)虚证(肾虚证)、风湿内扰证(风湿证)、湿热内蕴证(湿热证)。3.分析瘀痹证发生率、中医证候特点,以及与蛋白尿、肾功能、肾病理的相关性。4.147例患者分为3组,贝那普利组(西药组)48例、加味积雪草组(中药组)50例、加味积雪草+贝那普利组(中西药组)49例,分析3组治疗前后中医证候、蛋白尿、肾功能等变化。5.统计采用SPSS17.0统计软件分析。结果：1.慢性肾小球肾炎(CKD3期)肾络瘀痹证发生率69%,并常与肾虚、风湿、湿热等证型同时出现,其中瘀痹肾虚风湿三联证最多见,瘀痹肾虚二联证次之,单独瘀痹证少见。2.瘀痹肾虚二联证在瘀痹证总积分及肌肤甲错积分高于瘀痹肾虚风湿三联证(p<0.05)3.瘀痹证与24小时尿蛋白定量(UPro/24h)有相关性；尿血有不同于其他瘀血证症状特点,其与UPro/24h有相关性(p<0.01)。4.肾病理Andreoli评分提示CKD3期病理急慢性损伤并存,慢性损伤积分重于急性损伤,急性损伤中细胞性新月体比例较高,慢性损伤中节段性硬化比例较高。5.三组治疗后中医证候积分均较治疗前明显下降(p<0.01),中西药组尿血疗效优于西药和中药组(p<0.05)。5.中药组eGFR较治疗前明显升高,较西药组亦升高,但治疗后尿蛋白有增多(p<0.05)。西药组治疗后尿蛋白较中药组减少,差异有统计学差异(p<0.01)。中西药组治疗后较中药组、西药组蛋白尿减少,较西药组eGFR升高(p<0.05)。结论：1.慢性肾小球肾炎(CKD3期)肾络瘀痹证并不少见,并极大多数与其他证型并存,尤以与虚、风湿三联证多见。2.瘀痹证各症状中以镜下多形性红细胞尿持续存在最具特征,因此在中医辨证中引入尿象检测将有助于提高辩证精准度。3.肾病理Andreoli评分提示CKD3期病理急慢性损伤并存,慢性损伤积分重于急性损伤,急性损伤中细胞性新月体比例较高,慢性损伤中节段性硬化比例较高。4.中药、西药、中西药组均能明显改善慢性肾小球肾炎(CKD3期)肾络瘀痹证中医证候。在尿血治疗中,中西药组能有效减少尿血积分,优于西药和中药组。5.中药组有不依赖于减少尿蛋白的肾保护作用,并能较好改善患者的贫血。6.中西药组(中药与贝那普利的联合治疗)则既能有效减少尿蛋白,又能明显改善肾功能,延缓肾功能衰竭。更多还原

【Abstract】 Objective:To investigate Traditional Chinese Medical (TCM) characteristics, clinical pathological manifestation of ShenLuoYuBi (YuBi) symptoms in chronic glomerulonephritis (CKD3) patients and effects of jixuecao compounds, benazapril, combined with benazapril and jixuecao compounds.Methods:A multicenter double blind double dummy randomized controlled clinical study was applied. The patients who were Chronic glomerulonephritis (CKD3stage) had ShenLuoYuBi symptoms with ShenQiYinXu(ShenXu),FengShiNeiRao(FengShi) and ShiReNeiYun(ShiRe) symptoms respectively by syndromes differentiation. The correlations among occurrence rate of ShenLuoYuBi symptom, TCM characteristics, proteinuria, renal function and renal pathological manifestation were analyzed. The147patients were divided into benazapril (48patients), jixuecao compounds (50patients),combined with benazapril and jixuecao compounds groups (49patients). The SPSS17.0was applied.Results:Occurrence rate of ShenLuoYuBi symptoms in chronic glomerulonephritis (CKD3) patients was69%, accompanied with ShenXu, FengShi and ShiRe symptoms. The patients with two manifestations(YuBi and ShenXu symptoms) had higher scores of YuBi symptoms and squamous and dry skin than the patients with three manifestations (YuBi,ShenXu and FengShi symptoms)(p<0.05). The scores of YuBi symptoms were correlated with UPro/24h. The scores of hematuria which was different from other symptoms of YuBi were also correlated with UPro/24h (p<0.01). According to Andreoli’s scores, the patients in CKD3stage both had acute and chronic pathological injury of nephrology, and the scores of chronic pathological injury were higher than the acute injury. Among the acute pathological injury, the number of cellular crescent was greater than others. The scores of segment of glomerular sclerosis were highest in chronic pathological injury. TCM symptom markers in three groups were decreased after treatment (p<0.01). The scores of hematuria had been improved by combined with benazapril and jixuecao compounds treatment while jixuecao compounds or benazapril respectively had no effects (p<0.05). Proteinuria in the patients were increased significantly after treated with jixuecao compounds while e-GFR was raised (p<0.05). The UPro/24h of patients which treated with benazapril reduced effectively than the patients of jixuecao compounds (p<0.01).Proteinuria in the patients treated with benazapril and jixuecao compounds had decreased and renal function had been improved (p<0.05), and the results showed better effect than jixuecao compounds and benazapril treatment respectively.Conclusion:ShenLuoYuBi symptoms in chronic glomerulonephritis (CKD3) patients are common and accompanied with other TCM symptoms. Hematuria was correlated closely with CKD and would be useful in dialectics of YuBi symptoms in the future. Traditional medicine show renal protective effect independence of lowering proteinuria and improve anemia. Combined with benazapril and traditional medicine show lowering proteinuria and renal protective effect in CKD3patients.更多还原