【作者】 韦芳宁；

【导师】 杨霓芝；

【作者基本信息】 广州中医药大学 ， 中医内科学， 2010， 博士

【摘要】 背景慢性肾衰竭(CRF)为内科常见病之一,是各种肾脏疾病导致肾功能渐进性不可逆性减退,直至功能丧失所出的一系列症状和代谢紊乱所组成的临床综合征,其病情危重,死亡率高。西医非透析治疗的目的主要是缓解慢性肾衰症状和延缓病程进展,主要措施包括消除CRF进展的可逆因素；治疗原发病,如高血压病、糖尿病肾病等；抗感染,水电解质平衡等；优质低蛋白饮食,加必需氨基酸或酮酸；保护肾脏功能、减轻蛋白尿的血管紧张素Ⅱ酶转化酶抑制剂的应用；调节脂质代谢和改善肾小球局部存在高凝状态。中医中药治疗慢性肾衰以中药的单味药、单方、复方制剂及综合疗法,通过多环节、多层次、多途径综合治疗措施而达到缓解慢性肾衰症状,保护肾功能,延缓病程进展的目的。多年的临床实践经验表明,慢性肾衰的治疗,采用中西医结合的综合治疗,特别是中药介入治疗后,在缓解慢性肾功能衰竭症状,保护残余肾功能、延缓早中期肾功能进展、推迟进入透析和肾移植时间等方面取得了明显疗效,提高了CRF患者的生存质量。益气活血中药三芪口服液在慢性肾脏病的治疗以及改善慢性肾衰的症状,延缓慢性肾衰的病程进展,保护肾功能方面积累了一定的经验。本研究从细胞黏附因子、炎症因子、细胞凋亡和T淋巴细胞亚群上,多角度、多靶点研究三芪口服液的影响,旨在探讨中药介入慢性肾衰治疗的肾功能保护作用以及三芪口服液保护肾功能的作用机理。目的通过临床和实验研究观察益气活血中药三芪口服液对慢性肾衰病人及对5／6肾切除慢性肾衰大鼠模型肾脏病理形态和功能的保护作用,从分子生物学、细胞凋亡以及淋巴细胞免疫方面,探讨益气活血中药三芪口服液延缓CRF进展的机理。方法临床研究：选择纳入标准的病例95例,分为3组,三芪口服液组34例,尿毒清组30例,三芪口服液+尿毒清组31例,每组患者均按就诊顺序随机进入治疗组及对照组。12周后观察慢性肾衰的症状积分、血红蛋白、红细胞压积、血小板计数、血清白蛋白、尿素、肌酐、血钾、血小板膜α颗粒蛋白(PS)的变化。实验研究：选用SPF雄性SD大鼠102只。使用随机软件包PEMS3.1产生随机数字,按随机数字大小排序,等分为6组,每组17只,造模过程死亡24只,实际78只,空白组13只,模型对照组13只、三芪口服液高剂量组(TMH组)13只、三芪口服液中剂量组(TMM组)13只,三芪口服液低剂量组(TML组)13只、包醛氧淀粉组13只。建立大鼠5／6肾切除慢性肾衰的模型,造模成功后用三芪口服液口服进行干预治疗,12周后分别观察各组大鼠一般情况、肾功能、红细胞压积、血小板计数和血小板膜α颗粒蛋白的变化,以及光镜下肾小球组织的改变,细胞凋亡的分析,TNF-α、TGFβ1、PGDFBB以及CD4、CD8和CD68的变化。结果临床实验研究方面：治疗前后三芪口服液组中医症状积分比较,差异有统计学意义(P<0.05)。提示三芪口服液有改善慢性肾衰症状的作用。提示三芪口服液与尿毒清合用能明显提高临床治疗有效率,治疗有效率96.8%。三芪口服液能降低血尿素水平,提高血清白蛋白水平并可以下调PS的表达。治疗前后比较,差异有统计学意义(P<0.05)。口服三芪口服液,患者依从性较好,未发生出血及不良事件。基础实验研究：血生化方面,三芪口服液各剂量组均可降低造模大鼠的血尿素和血肌酐水平,中剂量可以提高造模大鼠的血红蛋白压积,高、中剂量可以降低造模大鼠的血小板,治疗前后比较有统计学意义(P<0.05)。细胞黏附因子方面,三芪口服液中、低剂量可以下调PS的表达。治疗前后比较有统计学意义(P<0.05)。在残肾病理组织学方面,三芪口服液可以使增大的肾小球面积明显缩小,可以减轻肾小管损伤程度。与包醛氧淀粉组比较,差异有统计学意义(P<0.05)。细胞因子研究方面,经三芪口服液治疗后,无论高、中、低剂量组,大鼠血清TNF-α、FPDGBB以及残肾组织的TGFβ1、FPDGBB水平均明显降低,与模型组比较,差异有统计学意义(P<0.05)。细胞凋亡方面,经三芪口服液治疗后,5／6肾切除大鼠慢性肾衰肾脏细胞凋亡率明显降低,与包醛氧淀粉酶组比较,差异有统计学意义(P<0.05)。淋巴细胞免疫方面,三芪口服液中、低剂量组可以显著上调CD4水平,使CD4／CD8比值明显上升,CD68水平下调,与包醛氧淀粉组比较,差异有统计学意义(P<0.05)。结论1.三芪口服液能改善慢性肾衰患者中医症状积分,提高临床治疗有效率。2.三芪口服液能提高慢性肾衰患者血清白蛋白水平,改善患者营养状态。3.三芪口服液能够通过下调慢性肾衰患者血浆PS的表达,改善患者的瘀血状态,从而改善患者肾小球微循环,此可能是保护肾功能的机制之一。4.三芪口服液能够降低5／6肾切除CRF模型大鼠的Scr水平,提高红细胞压积,改善机体整体状态。5.三芪口服液能减轻5／6肾切除大鼠的肾脏病理损害,使增大的肾小球面积明显减小,肾小管损伤程度明显减轻,对残肾组织的形态有保护作用,此可能是保护肾功能的作用机制之一。6.三芪口服液能抑制TNF-α、PDGFBB和TGFβ1的表达,减少肾小管损害,减少细胞增生,以此达到保护肾功能的目的。7.肾脏实质细胞的凋亡参与肾脏疾病的进展过程,可能是促进慢性肾硬化发生、发展的因素之一,三芪口服液能使5／6肾切除CRF模型大鼠凋亡细胞明显减少,从而抑制细胞凋亡参与的肾脏损伤,延缓慢性肾衰的进展。8.三芪口服液保护肾功能的机制可能与调整CD4和CD8的比例失调,调整异常的机体免疫紊乱和状态,减少了各种免疫受损的诱因有关,可能是其延缓CRF进展的机制之一。更多还原

【Abstract】 BackgroundChronic Renal Failure (CRF), a common disease, is a clinical syndrome of a variety of kidney diseases which lead to progressive irreversible kidney function decline until a loss of function through a series of symptom and metabolic disorders. Chronic renal failure is critical and with high mortality.The purpose of Western non-dialysis treatments for chronic renal failure is to relieve symptoms and delay progression. The main measures include slowing the progress of CRF reversible factors; treating of primary diseases such as hypertension and diabetic nephropathy; resisting of infections; maintaining a balance of water and electrolyte; delivering high quality and low protein diets, plus essential amino acids or keto acids; applying angiotensin converting enzyme inhibitor enzyme to reduce proteinuria and protect kidney function; regulating lipid metabolism; and improving the local presence of a glomerular hypercoagulable state.The Chinese medicine treatment for chronic renal failure in a single herb compound or combination therapy, utilizing multi-link, multi-level, multi-channel integrated measures to ease symptoms of chronic renal failure and protect renal function, thereby delaying progression.Years of clinical experience have shown that the treatment of chronic renal failure with a comprehensive application of Chinese and western medicines, especially after interventional treatment with Chinese medicine, alleviates symptoms of chronic renal failure, protects residual renal function and delays renal function decline as soon as early and mid-term progress. The comprehensive combination theraby delays dialysis and renal transplantation, resulting in improved quality of life for patients with CRF.Evidence supports that the Chinese medicine, Sanqi (radix astragali seu hedysari and Radix notoginseng)Oral Liquid, which has the effect of supplementing Qi and activating blood circulation, improves symptoms of chronic renal failure, delays the progression of chronic renal failure and protects renal function.In this study, cell adhesion factors, inflammatory factors, apoptosis and T cell subsets were observed. The multi-angle, multi-target effects of Sanqi Oral Liquid,a Chinese medicine, were observed after interventional treatment of renal function with Sanqi Oral Liquid.PurposeClinical changes were observed in Chronic renal failure patients using the Sanqi oral liquid. Experimental study of Chinese medicine Sanqi Oral Liquid was based on previous studies utilizing chronic renal failure rats in a 5/6 rephrectomy pathology model to ascertain the protective effect on kidney morphology and function to simulate chronic renal failure in patients.Using molecular biology, apoptosis, and lymphocyte levels, the effectiveness of Sanqi Chinese medicines Oral Liquid supplementing Qi and activating blood circulation in delaying the progress of CRF mechanism was studied.MethodsClinical Trials:95 patients were randomly divided into three groups:Sanqi groups, thirty-four pat ients received Sanqi Oral Liquid; Thirty patients were placed in the Niaoduqing group; Thirty-one patients received Sanqi Oral Liquid +Niaoduqing.Patients were separated into the treatment groups and control groups by visits, randomly. After 12 weeks, symptom scores, hemobl obin levels, hematorits, platelet counts, serum albumin, urea, creatine and potassium levels, as well as plateletαgranule membrane prote in changes were evaluated.Exper imental studies:78 SPF male SD rats, using the random number generated package PEMS 3.1 subjects were divided into 6 groups:control group-13, model control group-13, Sanqi Oral Liquid high-dose group (TMH) group-13, Sanqi Oral medium dose group (TMM) group-13, Sanqi Oral Liquid low-dose group (TML) group-13, including coated al dehyde oxystarch group-13. Rats in 5/6 nephrectomy model of chronic renal failure received Sanqi Oral Liquid interventional treatment. Then,12 weeks later the rats were observed in the general situation,their kidney function, hematocrit, platelet count and plateletαgranule membrane protein changes were registered. Pathologica! changes in glomerular state were studied under light microscope. Apoptosis analysis was conducted. TNF-α,TGFβ1,PGDFBB, and CD4, CD8 and CD68 changes were observed.ResultsClinical Trials:For the Sanqi Oral Liquid groups-a total efficiency of 82.4%; Sanq i Oral Liquid+Niaoduqing group-total efficiency of 96.8%. Compared to the Niaoduqing group, the differences were statistically significant (P<0.05). The Sanqi Oral Liquid group demonstrated significantly higher hematocrits and serum albumin and lower blood urea after treatment, compared to the Niaoduqing group (P<0.05). For the Sanqi Oral Liquid group before and after therapy, platelet a granule membrane protein (PS) decreased and the difference was statistically significant (P<0.05).Experimental Studies:In the Sanqi Oral Liquid group, the blood urea and serum creatinine decrease after treatment was statistically significant (P<0.05). The Sanqi Oral Liquid middle-dose (TMM) and low-dose (TML) PS group had a statistically significant low expression after treatment (P<0.05). In residual glomerular morphology, the Sanqi Oral Liquid treatment groups significantly reduced the increased glomerular area, tubularinjury was mild.Also in the coated aldehyde oxystarch group the difference was significance (P<0.05). In cytokine research, the Sanqi Oral Liquid treatment group, regardless of high, medium or low dosage decreased the expression level of TGFβ1, compared with the coated aldehyde oxystarch group, the difference was significant (P<0.05).Sanqi Oral Liquid in the middle dose group significantly reduced the increased in apoptosis,compared with the coated aldehyde oxystarch group, the difference was statistically significant (P<0.05).Sanqi Oral Liquid in the middle and low dose group significantly raised CD4 levels,CD4/CD8 ratio also significantly increased compared with the coated aldehyde oxystarch group, the difference was significant (P<0.05).Conclusions1. Sanqi Oral Liquid can improve clinical symptoms in patients with chronic renal failure points, improve clinical efficiency.2. Sanqi Oral Liquid can increase the level of serum albumin in chronic renal failure and improve nutritional status of patients. 3. Sanqi Oral Liquid can. decreases the blood expression lever of PS, improving the patient’s blood stasis state, thereby protecting renal function.4.Sanqi Oral Liquid can reduced the 5/6 nephrectomized CRF rats Scr, increase the hematocr its and improve the body statue, thereby delaying the progress of renal function decline.5. Sanqi Oral Liquid can improve the 5/6 nephrectomy rats’renal pathological changes and provide residual renal protective effects.6. Sanqi Oral Liquid can inhibit TNF-α,PGDFBB and TGFβ1 expression to renal hypertrophy,glomerular hyperfiltration state, etc.at different levels of mitigation, in order to achieve protection of renal function.7.Sanqi Oral Liquid may significantly inhibit renal parenchymal cell apoptosis involved in the progression of renal disease and inhibit chronic renal sclerosis in 5/6 nephrectomy CRF rats.8.Sanqi Oral Liquid’s protective effects on renal function may be related to adjustment of the ratio of CD4 and CD8 disorders, reducing adjustment disorders and immune abnormalities, resulting in a reduction of a variety of immune impairments and slowing the progress of CRF.更多还原