【作者】 肖惟丹；

【导师】 邱幸凡； 张六通；

【作者基本信息】 湖北中医药大学 ， 中医基础理论， 2010， 博士

【摘要】 目的在中医理论的指导下,结合“络脉络病理论”,探讨慢性肾衰的基本病机及其治疗方法和方药组成,并通过动物实验深入研究补肾解毒通络法的作用机理,为补肾解毒通络法在临床上的应用提供初步的实验依据。本文主要由理论探讨、实验研究和结论与探讨三大部分组成。理论探讨1、慢性肾衰的基本病机是肾虚络痹毒结。(1)肾脏亏虚是慢性肾衰发病的根本：肾藏精,为脏腑阴阳之本、生命之源,称其为“先天之本”。先天之本衰败,则容易受到内外邪气的侵袭,而邪气乘虚而入,日久化火灼阴,化热积毒,阻于肾络,影响肾的生理功能,从而导致慢性肾衰的发病。(2)络痹毒结是慢性肾衰的病理关键：肾病日久,肾脏亏虚一方面使其化生精微物质的能力下降,精亏血少,从而导致肾络失养,络病产生。另一方面使络中气血循环的动力下降,使病邪留滞,痰、瘀、毒形成,淤阻于肾络,导致络痹毒结。而肾络是气血营养肾脏的关键和枢纽,肾络畅、气血充,则肾脏得养而功能健旺；肾络痹、气血虚,则肾脏失养而功能衰竭。所以肾脏亏虚是慢性肾衰发病的根本,但是络痹毒结是其病理关键。(3)肾虚与络痹毒结相互影响,互为因果：慢性肾衰病程长,演变多,首先是肾脏功能受损,随着病情发展而波及脾胃、三焦、肝、心和肺等脏腑,导致五脏六腑的气血阴阳俱虚,但肾脏亏虚是其发病的关键。同时,肾虚导致肾络不荣,影响其运行气血、渗灌濡养等功能,使得气血虚滞不畅而致瘀血内生、津凝化痰、化热积毒,痹阻络脉。而肾络痹阻又影响着络中气血生化之机,从而加重肾虚,如此循环往复,加重病情。可见,在慢性肾衰的整个病程中,脏虚和络痹毒结相互影响,互为因果。2、补肾解毒通络法是治疗慢性肾衰的重要治法。肾虚络痹毒结是慢性肾衰的基本病机,因此,慢性肾衰的重要治法则是补肾解毒通络法。慢性肾衰的病情反复,虚实夹杂,故治当标本兼治,通补兼施,寓通于补,通不致虚,补不留邪,调理气血,恢复脏腑功能,冀使虚复、瘀除、痰祛、毒解。3、组方依据与方药分析。“补肾解毒通络法”的代表方剂为“补肾解毒通络方”,该方组成为：黄芪30g、淫羊藿20g、山茱萸15g、丹参30g、地龙15g、金银花15g、大黄6g。其中,黄芪合淫羊藿,补肾益气,共为君药；山茱萸、丹参、地龙、金银花,补肾、益气、化瘀、解毒、通络,共为臣药；大黄清热解毒、活血祛瘀,为佐使。全方合用,共奏补肾益气、清热解毒、活血通络之功。实验研究方法：按照文献方法采用腺嘌呤灌胃制作大鼠慢性肾衰模型。并在此基础上应用补肾解毒通络方开展对模型进行干预作用的实验研究。将SPF级雄性Wistar大鼠40只随机分为正常对照组(10只)和模型组(30只)进行模型制作。而后将造模成功的29只大鼠随机分为模型对照组、尿毒清组和补肾解毒通络方组分别进行给药干预。给药结束后,检测每组大鼠血肌酐、血尿素氨和转化生长因子-β1、肾组织Ⅰ型胶原、骨形态发生蛋白-7及其三者mRNA的表达。结果：1、血肌酐和血尿素氮：模型组和治疗各组BUN、Scr水平与正常组比均显著升高,有非常显著性差异(P<0.01)。尿毒清组、中药治疗组与模型组相比,BUN、Scr水平均显著降低,有非常显著性差异(P<0.01)。其中,中药治疗组BUN低于尿毒清组(P<0.05),而Scr值两者无显著性差异(P>0.05)。2、大鼠肾组织中Col-I蛋白的表达：与正常组相比,模型组、尿毒清组和中药治疗组Colla-Ⅰ蛋白的表达均显著增高,有非常显著性差异(P<0.01)。尿毒清组、中药治疗组能够抑制Colla-Ⅰ蛋白的表达,与模型组相比均显著降低,有非常显著性差异(P<0.01)。其中,中药治疗组低于尿毒清组,两者有显著性差异(P<0.01,P<0.05)。3、大鼠肾组织中TGF-β1蛋白的表达：与正常组相比,模型组、尿毒清组和中药治疗组TGF-β1蛋白的表达均显著增高,有非常显著性差异(P<0.01)。尿毒清组、中药治疗组能够抑制TGF-β1蛋白的表达,与模型组相比均有显著性差异(P<0.01,P<0.05)。其中,中药治疗组低于尿毒清组,两者有显著性差异(P<0.01,P<0.05)。4、大鼠肾组织中BMP-7蛋白的表达：与正常组相比,模型组、尿毒清组和中药治疗组BMP-7的表达均显著降低,有非常显著性差异(P<0.01)。尿毒清组、中药治疗组BMP-7的表达与模型组相比均显著增高,有非常显著性差异(P<0.01)。其中,中药治疗组高于尿毒清组,两者有显著性差异(P<0.01,P<0.05)。5、大鼠肾组织Col-ImRNA的表达：与正常组相比,模型组、尿毒清组和中药治疗组Colla-ImRNA的表达均增高,有显著性差异(P<0.05)。尿毒清组和中药治疗组Colla-ImRNA的表达低于模型组,与模型组相比均有显著性差异(P<0.05)。其中,中药治疗组Colla-ImRNA的表达低于尿毒清组(P<0.05)。6、大鼠肾组织中TGF-β1mRNA的表达：与正常组相比,模型组、尿毒清组和中药治疗组TGF-β11mRNA的表达均增高,有显著性差异(P<0.05)。尿毒清组和中药治疗组TGF-β1mRNA的表达低于模型组,与模型组相比均有显著性差异(P<0.05)。其中,中药治疗组TGF-β1mRNA的表达低于尿毒清组(P<0.05)。7、大鼠肾组织中BMP-7mRNA的表达：与正常组相比,模型组、尿毒清组和中药治疗组BMP-7mRNA的表达均降低,有显著性差异(P<0.05)。尿毒清组、中药治疗组BMP-7mRNA的表达与模型组相比均增高,有显著性差异(P<0.05)。其中,中药治疗组高于尿毒清组,两者有显著性差异(P<0.05)。结论：1、补肾解毒通络方可以减轻慢性肾衰大鼠的肾功能损伤。2、补肾解毒通络方可以减轻慢性肾衰大鼠的病理损伤,且效果优于尿毒清颗粒。3、补肾解毒通络方通过降低慢性肾衰大鼠肾组织中Col-Ⅰ、TGF-β1及其两者mRNA的表达,增高BMP-7和BMP-7mRNA的表达而减轻肾间质纤维化可能是其起延缓慢性肾衰进展的机制之一。4、补肾解毒通络方在影响Col-Ⅰ、TGF-β1、BMP-7及其三者mRNA的表达方面效果均优于尿毒清颗粒。更多还原

【Abstract】 Objective Probing the basic pathogenesis of chronic renal failure, its therapeutic methods and the composition of herbs under the direction of traditional chinese medicine theory combined with collateral disease theory, then through animal experiments to study the mechanism of the Bushen Jiedu Tongluo act, so as to effort warranty of the experiment for clinical application.The text was divided into three parts:theory probing, experiment al study and conclusion.Theory probing 1The basic pathogenesis of chronic renal failure is asthenia of kidney, venation obstruction and toxic factors accumulating in tissue. (1)The primary aspect of chronic renal failure is asthenia of kidney: kidney storing essence, being the organs of the yin and yang and trials of life.We call it"a priori of the present". Kidney deficiency and it vulnerable to the attack of internal-external influences, So evil can infiltrate by taking advantage of the other side’s unpreparedness, hurt Yin and accumulate poison for a long time which could obstruct kidney network, it affect various physiological function and structure of the kidney which lead to the incidence of chronic renal failure. (2) Venation obstruction and toxic factors accumulating in tissue are the pathological basis of chronic renal failure:Kidney is a priori of the present. On the one hand, insufficiency of kidney-qi cause the function of producing microscopic materials reduced, the kidney-essence and blood decreased, as that the kidney network dystrophy cause the function of communicating exterior and interior, infiltrating blood and fluids, and excreting body wastes reduced which lead kidney network malnutrition and collateral disease generate. On the other hand, it cause the power of blood circulation down which lead turbid phlegm, blood stasis and pathogenic toxin obstruct the kidney network. While the renal collaterals is the key and the hub of qi and blood for renal nutrition.If renal collaterals is clear, qi and blood is sufficient, then the kidney function was to support the healthy and vigorous; if renal collaterals is not clear, qi and blood is deficiency, kidney failure is the failure to support. (3) The two which is asthenia of kidney and which is venation obstruction and toxic factors accumulating in tissue interact, reinforce each other:chronic renal failure disease process is various reasons causes kidney damaged, so we lost two division, San Jiao damaged, the function of separating the clear from turbid decreased, damp turbidity and uremia can not be eliminated from the body while accumulate in the body which lead to venation obstruction. In turn, toxic factors accumulating in tissue injury righteousness, block air machine, increase the network weakness, so on and so on, adding condition.2. The main treatment of chronic renal failure is nourishing the kidney as well as removing toxic materials and dredging collaterals according to the pathogenesis:TCM establish treatment principles according to etiology, pathogenesis and pathological changes. The basic pathogenesis of chronic renal failure is asthenia of kidney, venation obstruction and toxic factors accumulating in tissue, so the main treatment of chronic renal failure is nourishing the kidney as well as removing toxic materials and dredging collaterals. Relapse of chronic renal failure cause that its treatment focuses on both the root and branch aspects, supporting healthy qi and removing pathogenic factors. So as that we can tonify deficiency, activate the blood, dissolve phlegm and detoxication.3 Prescription basis and recipe analysis:Prescription of Bushen Jiedu Tongluo act representative for the Bushen Jiedu Tongluo recipe which consisting of:astragalus 30g, epimedium 20g, fructus corni 15g, salvia miltiorrhiza 30g, earthworm 15g, honeysuckle 15g, rhubarb 6g. Meanwhile, astragalus and epimedium is monarch drug for reinforcing kidney and qi. Fructus corni, salvia miltiorrhiza, earthworm and honeysuckle is ministerial drug for reinforcing kidney and qi, removing blood stasis, expelling miasma, freeing channel. Rhubarb is assistant and guide for clearing heat and expelling miasma, promoting blood circulation by removing blood stasis. All side effects for tonifying qi of the kidney, clearing away heat and toxic material, activating blood and dredging collaterals.Experimental study Methods:The chronic renal failure rat models were caused by adenine according to literature method. The SPF-class male Wistar rats were randomly divided into two groups:normal control group and model group. After the success of modeling, the rats in model group were randomly divided into three groups:model control group、Niaoduqing group and Bushen Jiedu Tongluo group. After administration respectively,we observed BUN、Scr、transforming growth factorβ1、collagen typeⅠ、bone morphogenetic protein 7、TGFβ1mRNA、col-ImRNA and BMP-7mRNA. Results:1BUN and Scr:The points of BUN、Scr in the model group and treatment groups was higher significantly compared with the normal group(P<0.01).The points of BUN、Scr in the Niaoduqing group and Bushen Jiedu Tongluo group was decreased compared with model control group(P<0.01). The points of BUN in the Bushen Jiedu Tongluo group was decreased compared with Niaoduqing group (P<0.05), while the points of Scr between them had no significant difference(P>0.05).2Col-I protein: The expression of col-I in the model group, Niaoduqing group and Bushen Jiedu Tongluo group was increased compared with the normal group(P<0.01). The expression of col-I in the Niaoduqing group and Bushen Jiedu Tongluo group was decreased compared with the Model group (P<0.01). Bushen Jiedu Tongluo group and Niaoduqing group had significant difference (P<0.01, P<0.05).3 TGF-β1 protein:The expression of TGF-β1 in the Model group, Niaoduqing group and Bushen Jiedu Tongluo group was increased compared with the normal group(P<0.01). The expression of TGF-β1 in the Niaoduqing group and Bushen Jiedu Tongluo group was decreased compared with the Model group (P<0.01, P<0.05). Bushen Jiedu Tongluo group and Niaoduqing group had significant difference (P<0.01, P<0.05).4 BMP-7 protein:The expression of BMP-7 in the Model group, Niaoduqing group and Bushen Jiedu Tongluo group was decreased compared with the normal group(P<0.01). The expression of BMP-7 in the Niaoduqing group and Bushen Jiedu Tongluo group was increased compared with the Model group (P<0.01). Bushen Jiedu Tongluo group and Niaoduqing group had significant difference (P<0.01, P<0.05).5Col-ImRNA:The expression of Col-ImRNA in the Model group, Niaoduqing group and Bushen Jiedu Tongluo group was increased compared with the normal group(P<0.05). The expression of Col-ImRNA in the Niaoduqing group and Bushen Jiedu Tongluo group was decreased compared with the Model group (P<0.05). Bushen Jiedu Tongluo group and Niaoduqing group had significant difference (P<0.05).6TGF-β1mRNA:The expression of TGF-β1mRNA in the Model group, Niaoduqing group and Bushen Jiedu Tongluo group was increased compared with the normal group(P<0.05). The expression of TGF-β1mRNA in the Niaoduqing group and Bushen Jiedu Tongluo group was decreased compared with the Model group (P<0.05). Bushen Jiedu Tongluo group and Niaoduqing group had significant difference (P<0.05).7BMP-7mRNA:The expression of BMP-7mRNA in the Model group, Niaoduqing group and Bushen Jiedu Tongluo group was decreased compared with the normal group(P<0.05). The expression of BMP-7mRNA in the Niaoduqing group and Bushen Jiedu Tongluo group was increased compared with the Model group (P<0.05). Bushen Jiedu Tongluo group and Niaoduqing group had significant difference(P<0.05). Conclusion lBushen Jiedu Tongluo recipe could reduce renal function in rats with chronic renal failure.2 Bushen Jiedu Tongluo recipe could reduce the pathological damage in rats with chronic renal failure, and it was better than Niaoduqing.3 Bushen Jiedu Tongluo recipe could alleviate chronic renal failure and reduce the renal interstitial fibrosis by reducing the expression of Col-I、TGF-β1、Col-I mRNA and TGF-β1mRNA, increasing the expression of BMP-7 and BMP-7mRNA.4 The side of expression of Col-I、TGF-β1、BMP-7、Col-I mRNA、TGF-β1mRNA and BMP-7mRNA effected by Bushen Jiedu Tongluo recipe was better than its by Niaoduqing.更多还原