【作者】 薛武更；

【导师】 聂莉芳；

【作者基本信息】 中国中医科学院 ， 中医内科学， 2010， 博士

【摘要】 近年来全球范围的慢性肾脏病(chronic kidney disease,CKD)以及由此导致慢性肾功能衰竭(chronic renal failure,CRF)的发病率和患病率均明显升高,已经成为不可忽视的医疗问题和社会问题。因此,加强慢性肾衰的早期防治十分必要。从临床实践来看,在慢性肾衰的早中期,若中医药调治得当,则“可以明显地减轻甚至消除症状,不同程度地改善肾功能指标,改善生活质量及延缓肾衰进程,从而延长生命”。在慢性肾功能衰竭的中医治疗方面,通过长期临床探索和总结出来的名老中医的宝贵经验尤当值得继承、借鉴和发扬。在运用中医治疗慢性肾功能衰竭的实践中,不可避免的要涉及疗效评价的问题。在CRF患者长期的治疗过程中除了应用临床及有关生物学指标外,若再结合与健康有关的生存质量(Health-related quality of life, HRQOL)量表联合观察治疗反应,则能较全面的评价疾病及其治疗方法对病人造成的身体、心理和社会的影响,对治疗的结果做科学的分析和评价,帮助研究者获得全面正确的结论。而在慢性肾功能衰竭生存质量研究方面,目前主要集中在肾脏替代治疗领域,关于早中期慢性肾功能衰竭患者的生存质量鲜有报道。基于此,本文在总结导师聂莉芳教授论治慢性肾功能衰竭经验的同时,对124例早中期慢性肾功能衰竭患者的生存质量状况以及影响因素作了初步的调查分析；并以导师运用益气养阴法治疗慢性肾功能衰竭气阴两虚证的经验为基础,观察了益气养阴法对早中期慢性肾衰气阴两虚证患者近期生存质量的改善情况。本研究的创新点有二：①对早、中期慢性肾功能衰竭患者的生存质量状况以及影响因素进行横断面调查；②观察益气养阴法对早、中期慢性肾功能衰竭气阴两虚证患者生存质量的影响。1.导师聂莉芳教授运用中医药理论论治慢性肾衰的经验聂莉芳教授认为慢性肾衰的治疗包括治病和治人两个方面。治“病”的同时,必须考虑到患病的“人”这一因素。聂莉芳教授在以标本缓急理论分析了慢性肾功能衰竭“错综复杂”的中医病因病机和临床表现后,提出了慢性肾衰的中医临床分期,即将慢性肾衰分为虚损期和关格期。虚损期临床表现以一派虚损症状为主,其病机特点以正气虚衰为主,气阴两虚证较为多见。关格期病机特点以邪实为主,湿浊内停是其重心。聂莉芳教授认为慢性肾衰的中医治疗,应首辨病期,然后再辨证,将辨病期与辨证有机结合。虚损期病情相对较轻较缓,所以治疗应以缓则治本,扶助正气为主；关格期病情相对较重,所以治疗应以祛邪为主,兼顾扶正；若慢性肾衰患者病程中出现可逆因素时,则急则治标,迅速祛除可逆因素,解除病情的恶化趋势。虚损期若辨证属脾肺气虚证,治当补益脾肺之气,方药选用补中益气汤、参苓白术散等。若辨证属脾肾阳虚证,治当温补脾肾,方药选用保元汤、真武汤等。若辨证属肝肾阴虚证,治当滋养肝肾,平肝潜阳,方药选用杞菊地黄汤、麻菊地黄汤、归芍地黄汤等。若辨证属气阴两虚证,治当益气养阴,方药选用参芪地黄汤加泽泻。相对于虚损期而言,关格期病势急骤多变,病机特点以邪实为主。其治疗,应以祛邪为主兼以扶正,要权衡标本缓急,注意护养胃气,以调理脾胃为重心。若辨证属脾胃气虚,寒湿中阻证,治当健脾益气以调理脾胃,方药选用香砂六君子汤。若辨证属湿热中阻证,治当清化湿热以调理脾胃,方药选用黄连温胆汤、苏叶黄连汤、半夏泻心汤等。若慢性肾衰患者在病程中,因可逆因素而发生外感、水肿、小便不利、水凌心肺等情况时,其治疗当以祛邪为首务,根据患者具体情况对症治疗。应注意的是,因慢性肾衰患者正气虚馁,所以在施用祛邪法则时,要注意中病即止,以免徒伤正气,变生它疾。2.早中期慢性肾衰患者的生存质量及其影响因素研究目的：通过横断面调查,观察早中期慢性肾功能衰竭患者的生存质量状况及其影响因素。方法：病例选择自中国中医科学院西苑医院、北京中医药大学东方医院和北京军区总医院肾内科的早中期慢性肾功能衰竭患者124例。使用中文版SF-36量表进行问卷评价患者的生存质量。用李克累加法,按最后题值计算原始分数,再用标准公式计算转换分数。用SPSS13.0软件包分析数据。结果：(1)早中期慢性肾衰患者SF-36量表各维度得分均数由低至高排列,依次为：一般健康状况(GH)：36.24±12.97；生理职能(RP)：37.74±31.20；精力(VT)：52.60±20.75；情感职能(RE)：55.34±30.06；精神健康(MH)：59.20±17.85;社会功能(SF)：59.88±18.05；生理机能(PF)：79.11±14.87,躯体疼痛(BP)：79.60±19.14。早中期慢性肾衰患者生存质量水平在生理机能(PF)、生理职能(RP)、一般健康状况(GH)、社会功能(SF)、情感职能(RE)维度得分显著低于普通人群；早中期慢性肾衰患者生存质量水平在生理机能(PF)、生理职能(RP)、躯体疼痛(BP)、一般健康状况(GH)、社会功能(SF)、情感职能(RE)维度得分显著高于血透人群。(2)影响早中期慢性肾衰患者生理因素综合得分(PCS)的因素有性别、年龄和Scr值。影响早中期慢性肾衰患者心理因素综合得分(MCS)的因素主要是文化程度。男性患者在生理职能(RP)、躯体疼痛(BP)、一般健康状况(GH)、精力(VT)、精神健康(MH)的维度得分明显高于女性患者,差异有统计学意义(P<0.05)。三个年龄段患者之间,生理机能(PF)和精力(VT)的维度得分差异有统计学意义(P<0.05),年龄段越低,得分越高。三组不同文化程度患者之间,精力(VT)和精神健康(MH)的维度得分差异有统计学意义(P<0.05),文化程度越高,得分越高。患者生存质量与Scr呈负相关,Scr越低(即eGFR越高),得分越高。eGFR为“60-89ml／min”患者在生理职能(RP)、一般健康状况(GH)、精力(VT)维度的得分明显高于eGFR为“30-59ml／min”患者的得分。结论：(1)早中期慢性肾衰患者生存质量总体水平低于普通人群。(2)影响早中期慢性肾衰患者生存质量的因素有性别、年龄、Scr值和文化程度。3.益气养阴法对早中期慢性肾衰气阴两虚证患者生存质量影响的临床研究目的：观察益气养阴法对早中期慢性肾衰气阴两虚证患者生存质量的影响。方法：采用平行对照的方法,将入选的57例患者分为治疗组(30例,来自中国中医科学院西苑医院)和对照组(27例,来自北京军区总医院)。对照组采用西医慢性肾脏病一体化疗法治疗,治疗组在西医对症治疗的基础上,加用益气养阴之参芪地黄汤加减治疗。应用中文版SF-36量表进行问卷评价患者的生存质量。各组患者在治疗前和治疗3个月后各测评1次。用李克累加法,按最后题值计算原始分数,再用标准公式计算转换分数。用SPSS13.0软件包分析数据。结果：治疗组患者治疗后的生理因素综合测评(PCS)、心理因素综合测评(MCS)及总体生存质量(总分)、Scr值与治疗前相比有非常显著性差异(P<0.01)。从各维度来看,治疗后精力(VT)、生理职能(RP)、一般健康状况(GH)、情感职能(RE)精神健康(MH)的得分明显高于治疗前(P<0.01或P<0.05)。经意向性分析,对照组患者治疗后的生理因素综合测评(PCS)、心理因素综合测评(MCS)及总体生存质量(总分)与治疗前相比有非常显著性差异(P<0.01)。从各维度来看,治疗后生理职能(RP)、躯体疼痛(BP)、一般健康状况(GH)、精神健康(MH)精力(VT)的得分明显高于治疗前(P<0.01或P<0.05)。经意向性分析,治疗后对照组和治疗组的生理职能(RP)维度得分有显著性差异(P<0.05),治疗组高于对照组。其余得分没有显著性差异。结论：与治疗前相比,两组治疗均对早中期慢性肾衰气阴两虚证患者近期的总体生存质量有明显的改善作用,但还不能认为两组间的治疗疗效有差别。更多还原

【Abstract】 In recent years, the increasing incidence and prevalence rates of the chronic kidney disease(CKD) and which cause chronic renal failure(CRF) around the world, have become an overlooked medical and social problems.Therefore,it is necessary to enhance the early prevention and treatment of chronic renal failure.In early to middle stages of chronic renal failure,if patients of CRF were treated properly by Chinese medicine,their symptoms would be reduced or even eliminated, the renal function and quality of life would be improved,thus delay the process of CRF with varying degrees. And it was very important of the clinical experience of famous experts of Chinese medicine from long-term clinical practice.On clinical evaluation of chronic renal failure treated by Chinese medicine,based on clinical and biological indexes, the health-related quality of life(HRQOL) scale was combined,then it was more comprehensive for the effect evaluation of chronic renal failure.At present,there were lots of research on quality of life(QOL) of end-stage renal disease,but few research on early to middle stages of chronic renal failure.Therefore, the quality of life and its related factors of 124 cases with early to middle stages of CRF was investigated.At the same time, reinforcing Qi and nourishing Yin’s effect on recent quality of life of early to middle stages of CRF’s patients with syndrome of dual deficiency of qi and yin was observed which based on the my tutor’s clinic experience of CRF. The innovations of my paper are two aspects:①The quality of life and its related factors of patients with early to middle stages of CRF was investigated by the cross-sectional survey;②Reinforcing qi and nourishing yin’s effect on recent QOL of early to middle stages of CRF’s patients with syndrome of dual deficiency of qi and yin was observed.1.My tutor’s clinic experience of CRF by Chinese medicineAfter analyzing the complex pathogenesis and clinical manifestations of CRF by the theory of "tip and root"and"chronic and acute",my tutor put forward the view on TCM’s clinic stages of CRF,including"deficiency stage" and "block and repulsion stage".The manifestations of "deficiency stage"were lots of deficiency symptoms due to the pathogenesis of healthy qi deficiency. The pathogenesis of "block and repulsion stage"was pathogenic qi excess mainly,and internal obstruction of dampness turbidity was key.My tutor thinked that the basic concept of treating CRF was the combination of "treating disease"and "treating person". And the basic principles of treating CRF by Chinese medicine was the combination of differentiating stages and differentiating syndromes was of very importance for the treatment of CRF by Chinese medicine.In contrast,the condition of "deficiency stage"was mild ralatively,so the principles of therapy was mainly reinforcing healthy qi and treating the root.(1) spleen-lung qi deficiency syndrome,treated by Buzhongyiqi decoction,or Shenlingbaizhu powder preparation;(2)spleen-kidney yang deficiency syndrome,treated by Baoyuan decoction,or Zhenwu decoction;(3) liver-kidney yin deficiency syndrome,treated by Qijudihuang decoction,or Majudihuang decoction,or Guishaodihuang decoction;(4) syndrome of dual deficiency of qi and yin,treated by Shenqidihuang decoction.The condition of block and repulsion stage"was heavier, so the principles of therapy was eliminating the pathogenic factors mainly, reinforcing healthy qi following.(1) syndrome of internal obstruction of cold-dampness,treated by Xiangshaliujunzi decoction;(2)syndrome of internal obstruction of dampness-heat,treated by Huanglianwendan decoction.In the course of CRF,if there were reversible factors (such as external contraction,edema,urination, water qi intimidating the heart and lung),they should be treated firstly to eliminating theose factors, namely treating the tip (acute) before the root (chronic).2. Quality of life in patients with chronic renal failure and its influencing factorsObjective:To analyze the quality of life (QOL) of patients with early to middle stages of CRF,and the influencing factors of the QOL.Methods:124 patients coming from Xiyuan Hospital of China Academy of Chinese Medical Sciences,Dongfang hospital affiliated Beijing university of TCM,the military general hospital of Bejing PLA.QOL were investigated by SF-36 health survey of Chinese version. Statistical analysis were completed by using SPSS13.0.Results:(1) The each scale’s scores of SF-36 Health Survey were:GH:36.24±12.97,RP:37.74±31.20, VT:52.60±20.75,RE:55.34±30.06,MH:59.20±17.85,SF:59.88±18.05, PF:79.11±14.87,BP:79.60±19.14.They were worse than scores of general population,but higher than scores of patients with hemodialysis.(2) The influencing factors on PCS of patients with early to middle stages of CRF were gender,age and serum creatinine. The influencing factor on MCS of patients with early to middle stages of CRF was education. The influencing factor on total score of patients with early to middle stages of CRF was serum creatinine.The RP,BP,GH,VT and MH scores in male patients were higher than those in female patients.There was signifant difference(P<0.05).Among three age groups,the VT and PF scores’difference was significant (P<0.05).The age was lower,the score was higher. Among three education groups,the VT and MH scores’difference was significant (P<0.05).The education was lower, the score was higher. The scores of RP、GH、VT、PCS in stage 2 of CKD(eGFR was 60-89ml/min)were higher than those in stage 3 of CKD(eGFR was 30-59ml/min) (P<0.05 or 0.01).Conclusion:(1) The quality of life (QOL) of patients with early to middle stage of CRF was worse than general population.(2)The influencing factors were gender,age,education and Scr.3.The research on reinforcing qi and nourishing yin’s effect on recent QOL of early to middle stages of CRF’s patients with syndrome of dual deficiency of qi and yin.Objective:To evaluate the reinforcing qi and nourishing yin’s effect on recent QOL of early to middle stages of CRF’s patients with syndrome of dual deficiency of qi and yin.Methods:57 cases were divided into treatment group and control group.30 cases in treatment group from Xiyuan Hospital of China Academy of Chinese Medical Sciences,and 27 cases in control group from the military general hospital of Bejing PLA.Integrated treatment of chronic kidney disease was carried out in control group.Shenqidihuang decoction was carried out in treatment group based on symptomatic treatment of western medicine.The QOL were investigated by SF-36 health survey of Chinese version before treatment and 3 months after treatment respectively. Statistical analysis were completed by using SPSS13.0.The analysis of ITT was carried out.Results:the plan of treatment group could increase the scores of VT,RP,GH,RE and MH,and decrease the Scr.Compared with before treatment,there was a significant difference(P<0.01 or P<0.05).Thus the scores of physical component summary(PCS) and mental component summary(MCS) were increased,and compared with before treatment,there was very significantly difference(P<0.01).The plan of control group could increase the scores of VT,RP,GH,BP and MH.Compared with before treatment,there was a significant difference(P< 0.01 or P< 0.05) by ITT analysis.Thus the scores of PCS and MCS were increased,and compared with before treatment,there was very significantly difference(P<0.01) by ITT analysis.After treatment,there was no significant difference (P>0.05) except RP(P<0.05) between treatment group and control group.Conclusion:The effect on reinforcing qi and nourishing yin based on symptomatic treatment of western medicine was significant for the recent QOL of early to middle stages of CRF’s patients with syndrome of dual deficiency of qi and yin.It can improve the patients’recent QOL(includingRP、GH、VT、MH、RE).But the effect between two groups for patients’recent QOL was no significant difference.更多还原