慢性肾脏病MIA综合征中医证候的初步探讨

【作者】 伍玉娟；

【导师】 李秀英； 饶向荣；

【作者基本信息】 北京中医药大学 ， 中医内科学， 2011， 硕士

【摘要】 近年来,营养不良、炎症及动脉粥样硬化三者之间的相互因果关系逐渐被人们所认识,Stenvinkel等对109名透析前终末期肾功能衰竭患者进行研究发现,有22%存在营养不良、炎症及动脉粥样硬化三种情况。随后的研究提示存在营养不良、炎症及动脉粥样硬化综合征(MIAs)。MIAs严重影响着慢性肾衰竭患者的生存质量和预后。目前中医药对CRF营养不良、CRF炎症、CRF动脉粥样硬化各个部分的研究非常活跃,以中医药为主治疗慢性肾衰竭取得较好的疗效,故中西医结合治疗CRF可能有较好的前景。但目前MIAs的中医研究尚处于初步阶段,故对MIAs中医病因病机、辨证分型进行研究,以给予针对性的中医药治疗非常重要。研究目的：总结出CKD-MIA综合征的中医证候分布规律,主要证候特征；分析MIAs证型与临床营养不良、炎症和动脉粥样硬化的相关性；为中医药对CKD-MIA综合征的辨证立法、遣方用药提供临床基础资料。研究方法：采用横断面调查,对所有纳入病例进行中医辨证、中医虚损证和邪实证评分、SGA评分、透析患者同时进行MIS评分；采集入口学、病史及各种临床资料,包括：性别、年龄、身高、体重,计算体重指数BMI=BW (kg)/身高2(m2)、血压、个人嗜好、血肌酐、尿素氮、血清白蛋白、前白蛋白、转铁蛋白、总胆固醇、甘油三酯、钙、磷、全段甲状旁腺素、血红蛋白、超敏C反应蛋白、白介素6、肿瘤坏死因子α及颈动脉超声测定颈动脉内-中膜厚度；记录既往诊断明确的心脑血管及周围动脉疾病。血透患者透析前取血。分析各项临床指标之间的关系及其与虚损证和邪实证积分之间的关系。资料相关分析采用Spearman相关分析,组间比较采用秩和检验,P<0.05认为具有显著差异。研究结果：1.慢性肾脏病MIA综合征患者临床症状：最常见的临床症状为倦怠乏力、腰酸膝软、气短懒言、面色晦暗、畏寒肢冷、肢体麻木、食少纳呆、胸闷憋气、口干咽燥、头身困重。2.慢性肾脏病MIA综合征患者临床证候：最常见虚损证证型为脾肾气虚(43.9%),最常见的邪实证为血瘀证(73.17%)及各种湿邪(包括湿浊、湿热、水湿、痰湿)MIA综合征患者中,轻中度营养不良患者脾肾气虚证型多见,重度营养不良患者阴阳两虚证型多见。虚损证积分与邪实证积分之间存在正相关。3.营养不良、炎症和动脉硬化指标之间的关系：Hs-CRP与MIS存在正相关,Hs-CRP与PA存在负相关,Hs-CRP与CHO、LDL存在负相关,说明微炎症状态是引起营养不良与动脉粥样硬化的重要原因。4.营养不良、炎症和动脉硬化指标和中医证候之间的关系：1)邪实证积分与理化指标中的ALB水平呈负相关,提示MIA患者的临床邪实症状可能随着白蛋白水平的降低而加重。2)炎症因子IL-6与湿浊证、湿热证存在正相关,说明湿浊、湿热证与血清IL-6水平升高有一定相关性。3) IMT与湿热证、血瘀证存在正相关,说明湿热瘀血互阻,结聚血脉,可能是CKD患者动脉粥样硬化发生的病机之一。上面的结果提示以下结论：慢性肾衰竭MIA综合征的证型特点是虚实夹杂,其临床最常见的中医虚损证型是脾肾气虚,其邪实的特点是多湿多瘀；经过对CKD-MIA患者的营养不良、炎症和动脉硬化临床指标和中医的正虚、邪实证候的相关性分析,印证了在MIA患者中,存在因虚致实和因实致虚的密切相关的两种病机变化。根据患者存在的正虚和邪实证候的临床实际,扶正驱邪仍然为MIA治疗的重要法则,且健脾益肾,益气活血,祛湿泻浊可能是MIA综合征主要治法。本课题纳入慢性肾脏病MIA综合征患者41例。采用流行病学方法进行横断面研究,将所采集的中医症状、临床资料、理化检查数据、各种辅助检查运用现代统计学方法对MIA综合征的中医证候进行了初步分析。更多还原

【Abstract】 In recent years, malnutrition, inflammation and atherosclerosis of causal relationship among each other was gradually known by people, Stenvinkel etc found that 22 percent of 109 before dialysis patients with end-stage renal failure existing malnutrition, inflammation and atherosclerotic three kinds of cases. Subsequent research suggests the presence of malnutrition, inflammation and atherosclerosis syndrome (MIAs).MIAs affects the survival of patients with chronic renal failure quality and prognosis. Traditional Chinese medicine in CRF patients MIAs research mainly is very active, chronic renal failure with Chinese medicine treatment of MIAs achieved good curative effect, so combining traditional Chinese and western medicine treatment to MIAs may have good prospects. But now MIAs Traditional Chinese medicine research is still at a Preliminary stage, So it is very important to explore the etiology, pathogenesis, differential diagnosis of CKD-MIAs to give it target treatmentsObjective: to summarize. traditional. Chinese medical syndrome distribution law and main syndrome features of CKD-MIA syndrome; to explore the relationships among MIAs syndrome types, clinical nutrition, inflammation and atherosclerosis; to provide the clinical based data for Traditional Chinese medicine in order to instruct dialectical legislation and the oprescription of CKD-MIA syndromes.Methods:cross-sectional survey was adopted to collect materials and differ ential diagnosis of 41 CKD-MIAs patients with the inclusive criteria and the ir degrees of excessive-syndromes and deficiency-syndrome were scored, and S GA score, dialysis patients by MIS score simultaneously. Explore the relatio nship between the scores and various clinical index such as blood urea nitro gen (BMI= BW/height2), blood pressure, personal hobby, past medical hist ory, serum creatinine, urea nitrogen, serum albumin, former albumin, transfe rrin, cholesterol, triglyceride, calcium, phosphorus, the entire section of parathyroid hormone, hemoglobin, high-sensitivity C-reactive protein, interl eukin-6, tumor necrosis factor-αand carotid ultrasound determination abnor mal carotid intimal-media thickness;Record previous diagnosis cerebrovascula r and peripheral artery disease. hemodialysis patients take blood Before dial ysis. Spearman Correlation and Rank Sum Test were used. P< 0.05 is consid ered significant. Results:1. clinical symptoms of chronic kidney disease: the most common symptom were lassitude and weakness, waist sour knee soft, shortness of breath and lazy to talk,dim complexion, chills limb cold, numbness of the limbs,poor appetite, Bosom frowsty breath-holding, mouth parched and throat scorched, Head body trapped heavy.2. clinical syndrome of chronic kidney disease:The most common deficiency-syndrome among MIAs patients was Qi-deficiency in spleen and kidney, accounting for 43.9% and the most common excessive-syndrome among them was blood-stasis, accounting for 73.17%, and various dampness syndromes such as retention of dampness, damp-heat, pathogenic dampness, and phlegm-damp. among MIAs patients, The type of Qi-deficiency in spleen and kidney is more common in Mild-to-moderate malnutrition kidney and Yin and Yang deficiency syndrome is more common in Severe malnutrition.Scores of deficiency-syndrome had a positive correlation with that of excessive-syndrome3. The relationship among Malnutrition, inflammation and the arteriosclerosis: CRP levels had a positive correlation with MIS score, CRP levels might be negatively correlated to PA levels, CRP levels might be negatively correlated to CHO and LDL levels among them, explain that micro inflammation is the important reasons for causing malnutrition and atherosclerosis.4. The relationship between the syndromes and Malnutrition, inflammation and atherosclerosis index:1) Scores of deficiency-syndrome had a nagative correlation with ALB levels, suggesting served patients for clinical symptoms and the firm with albumin levels lower and heavier. suggesting that the deficiency-syndrome might tend to increase as the level of albumin levels decreased.2) Inflammatory factor IL-6 had a positive correlation with dampness and damp-heat.3) IMT had a positive correlation with damp-heat and blood-stasis. indicates that the damp-heat and blood stasis were mutual resistance in vascellum, may be one of the pathogenesis of atherosclerosis.The above results indicate the following conclusions:The characteristic syndrome of ARAS patients was deficiency in the origin and excess in superficiality, with Qi-dificiency of spleen and kidney as its most common clinical deficiency-syndrome, and blood-stasis and pathogenic dampness as its most common pathogenic factors. After Analysing to the clinical indicators of malnutrition、inflammation、atherosclerosis and deficiency-syndrome or excessive-syndrome. Proved by MIA patients, existing the two kinds of pathological changes that it is closely relation between coexistent deficiency and excess. According to patients with existing of deficiency-syndrome and excessive-syndrome, centralizer exorcisms is still one important rule for treatment, and Strengthening spleen, nourishing kidney, promoting blood circulation and removing dampness may be mainly Treatment for MIA syndrome.更多还原