肾性骨病患者中医证候特征与透析龄、原发病及其生存质量的相关性研究

【作者】 马驰；

【导师】 张宁；

【作者基本信息】 北京中医药大学 ， 中医内科学， 2012， 硕士

【摘要】 肾性骨病(Renal osteodystrophy, ROD)是慢性肾功能不全患者常见的并发症,几乎累及慢性肾脏病终末期的所有患者。ROD是由慢性肾功能衰竭导致钙磷代谢紊乱的一种骨骼形态学变化的代谢性骨病,可引起骨强度的改变、骨生长的异常,进而加重钙磷代谢的紊乱,引起皮肤瘙痒、贫血、神经系统及心血管系统损害等,严重影响了患者的存活率及生存质量。随着血液透析技术的发展,慢肾衰患者的存活率及生存时间得到了提高与延长,因而其生存质量受到了广泛的关注。随着慢性肾衰竭患者的增加,肾性骨病日益增多,近年来在西医常规治疗肾性骨病的基础上,联合中医药治疗在防治肾性骨病方面发挥了巨大的作用,优势逐渐显现。本课题采用横断面研究,观察了不同透析龄及原发病肾性骨病患者证候分布规律及不同证候、透析龄患者的生存质量,探索不同透析龄及原发病患者的中医证候分布特征、演变规律,及不同证候、透析龄患者的生存质量变化特点。1研究目的本研究通过对长期维持性血液透析的慢性肾衰肾性骨病患者进行横断面观察,统计观察其在不同透析龄及不同原发病的中医证候分布规律特点,及不同证候、透析龄患者的生存质量,为临床联合中医药治疗肾性骨病提供相对客观评价依据。2研究方法入选符合纳入标准的肾性骨病患者,共192例,对所有入组的患者进行症状学调查并记录,根据肾性骨病中医证候特点对所有入选病例进行辨证分型,分为阴阳两虚、痰瘀互阻(a),阳虚湿盛、痰浊内阻(b),阴虚内热、痰浊内阻(c)三组。①观察各组患者在不同透析龄(≤36月A、36-72月B、>72月C三组)及不同原发病(慢性肾小球肾炎Ⅰ、糖尿病Ⅱ、高血压Ⅲ、其他Ⅳ四组)出现频率及分布特征；②研究对比所纳入的192例肾性骨病患者中a、b、c三组不同证候患者的生存质量,及A、B、C三组不同透析龄患者的生存质量。3研究结果3.1不同透析龄ROD,患者的中医证候分布透析龄小于36个月及透析龄为36～72个月的ROD患者中阴阳两虚、阳虚、阴虚三组的分布无明显差异。而透析龄大于72个月的患者中阴阳两虚型所占比例最高(55.6%),阴虚及阳虚型分布相对较少,且两组间无明显差异。3.2不同原发病ROD患者的中医证候分布①原发病为慢性肾小球肾炎的患者中阴阳两虚型所占比例最高,阴虚与阳虚型较少。②原发病为糖尿病的患者中阴虚型所占比例最高,阴阳两虚型次之,阳虚型最少。③原发病为高血压的患者中各型分布无显著差异。④原发病为其他的患者各证候分布为阴阳两虚最多,阳虚次之,阴虚型最少。3.3不同透析龄组的原发病分布情况随着透析龄的增长原发病为慢性肾小球肾炎的患者逐渐增多,糖尿病肾病的患者逐渐减少,而原发病为高血压的患者分布无明显规律。3.4ROD患者生存质量与中医证候的关系生理功能、躯体疼痛、总体健康方面：a组最差,b、c组间无明显差异；生理职能、精力评分、社会职能方面：a组最差,且较b、c组有非常显著性差异(P均<0.01),而b、c组间无明显差异；感情职能方面：a组与b、c组无明显差异,c组较b组理想；心理健康方面：c组最理想,b组次之,a组最差；生理健康总测量：a组最差,b、c较之理想；精神健康总测量：c组最理想,b组次之,a组最差；生存质量总分评价：a组最差,b、c较之理想。3.5ROD患者生存质量与透析龄的关系生理功能、生理职能、躯体疼痛、精力评分、社会职能方面C组患者最差,A组最理想；一般健康状况：A最优,C次之,B最差；感情职能：A最差,C次之,B最优；心理健康：C最优,B次之,A最差；生理健康总测量：A最优,B次之,C最差；精神健康总测量：B最优,A次之,C最差；生存质量总分：B最优,A次之,C最差。4结论4.1ROD患者的证候变化特点基本符合疾病发展规律的趋势,伴随透析龄及病程的渐长,阴阳两虚、痰瘀互阻证最为常见,与肾性骨病的本虚标实、虚实夹杂的病机特点一致。4.2原发病为慢性肾小球肾炎的ROD患者多见阴阳两虚证,原发病为糖尿病的患者多见阴虚型及阴阳两虚型,阳虚型较少,原发病为高血压的患者中证候分布无显著差异,其分布特点考虑与各原发病本证之病机特点相关,可以作为中医辨证施治的参考依据。4.3原发病为慢性肾小球肾炎的患者透析龄较长,生存时间相对较长,糖尿病肾病的患者透析龄较短,生存时间相对较短。4.4阴阳两虚组患者在涉及生理健康方面的生存质量评分最差；在涉及心理健康方面的生存质量评分,阴虚组最理想,阳虚组次之,阴阳两虚组最差,符合肾性骨病病机发展规律；但阴虚组较阳虚组心理健康理想,可能与阳虚型患者脾肾阳虚的病机特点有关,以上规律为中医早期介入对证治疗以改善患者生存质量提供了依据。4.5透析龄大于72个月的患者在涉及生理健康方面的生存质量评分最差,透析龄为36-72个月的患者次之,小于36个月的最理想；涉及精神健康方面的生存质量评分透析龄在36～72个月的患者最理想,小于36个月的次之,大于72个月的最差。更多还原

【Abstract】 Renal osteodystrophy (ROD) is common in patients with chronic renal insufficiency complications, almost involving the end-stage of chronic kidney disease patients. ROD lead to morphological changes in metabolic bone of a skeleton of calcium and phosphorus metabolism disorders, chronic renal failure can cause changes in bone strength, bone growth abnormalities, thereby increasing the calcium and phosphorus metabolism disorders, itching of skin, anemia nervous system and cardiovascular system damage, a serious impact on patient survival and quality of life. With the development of hemodialysis, chronic renal failure patients, the survival rate and survival time to improve and extend, and thus their quality of life has received extensive attention. With the increase of patients with chronic renal failure, renal osteodystrophy increasing number in recent years on the basis of conventional Western medicine treatment of renal osteodystrophy, the joint treatment of Chinese medicine has played a huge role in the prevention and treatment of renal osteodystrophy, the advantage is gradually emerging. This topic is cross-sectional study to observe the quality of life of renal osteodystrophy in patients with different dialysis age and evidence of the primary disease syndrome distribution law, and different syndromes, dialysis age of patients, and explore each dialysis age and primary disease of TCM syndrome distribution features, evolution, and different syndromes, change characteristics of the patient’s quality of life of dialysis age.1Research PurposesIn this study, cross-sectional observation of the long-term hemodialysis patients with chronic renal failure, renal osteodystrophy, the statistics observed in different dialysis age and primary disease of TCM syndrome distribution laws of the characteristics of different syndromes, patients with dialysis agequality of life, relatively objective evaluation based on clinical joint Chinese medicine treatment of renal osteodystrophy.2Rresearch MethodsSelected met the inclusion criteria in patients with renal osteodystrophy, a total of192cases, symptomatology survey and record all the enrolled patients, according to the renal osteodystrophy of TCM syndrome type designate the characteristics of all eligible cases, divided into yin and yang, twotrue, phlegm and resistor (a), yang and dampness, phlegm, internal resistance (b), yin deficiency heat, phlegm resistance (c) three.①observation of patients in each group at different dialysis age (≤36months A, B,36to72months,72months C groups) and the primary disease (chronic glomerulonephritis Ⅰ, diabetes Ⅱ, hypertension Ⅲ, other IV four groups), the frequency and distribution characteristics;(2) included in the study compared192cases of patients with renal osteodystrophy, a, b, c three groups of different syndromes of survival quality, and A, B, C, three different groups of patients with dialysis age of survival quality.3Results3.1Distribution of TCM syndromes in different dialysis agesDialysis age less than36months and dialysis age of the patient population of36to72months of patient population in the yin and yang, yang, yin deficiency group, no significant difference in the distribution. The yin and yang the highest proportion (55.6%) in patients with dialysis age greater than72ROD, the yin and yang type of distribution is relatively small, and no significant difference between the two groups.3.2Distribution of TCM syndrome type in different primary diseases(1) Primary disease of yin and yang in the group of patients with chronic nephritis the highest proportion (46.8%).(2)Primary disease of yin deficiency in the diabetes group the highest proportion (48.3%), yin and yang, followed by (38.3%), Yang and type at least (13.3%).(3)No significant difference in various types of distributions of the primary disease patients with hypertension.(4)Original incidence of three common complications of syndromes of yin and yang (51.7%), Yang (27.6%), followed by yin deficiency (20.7%) at least.3.3Distribution of the primary disease in different ages of the dialysis ROD patientsWith the gradual increase dialysis age growth of the primary disease for patients with chronic glomerulonephritis, diabetic nephropathy in patients gradually reduced the original incidence of hypertension in patients with no obvious regularity.3.4The relationship between iPTH and TCM syndrome, dialysis age, primary diseaseThree different TCM syndrome and primary disease in patients with iPTH levels between the two groups were no significant differences (P>0.05); three different groups of patients with dialysis age of serum iPTH levels were significant differences (P values<0.05), and a gradually increasing trend with the dialysis age grew.3.5Quality of life of patients with ROD and TCM syndromeNo significant difference between the physiological function, bodily pain, general health:a group of the worst, b, c group; physiological functions, energy ratings, social functions:a set of the worst, and significant differences compared to b, c (all P<0.01), while b, c group, no significant difference between; feelings of functions:a group no significant difference in b, c, c group than in the group b ideal; mental health:c group the best group b followed by a group of mental health the worst; physical health measurement:the worst group a, b, c compared to the ideal, but between the two groups no significant difference; mental health measurement:a very significant difference among the three groups, and c the best group, followed by group b, a group of the worst; quality of life score evaluation:a group of the worst, b, c compared to the ideal, but there were no significant differences.3.6Quality of life of patients with ROD and dialysis agePhysiological functions, physical function, bodily pain, energy ratings, social functions, group C patients with the worst group A the best; the general state of health:the optimal A, C, followed by B the worst; feelings of functions:the worst A, C, followed by B is best; mental health:the optimal C, followed by B, A, the worst; physical health measurements:A, the best, followed by B, C the worst; mental health measurement:the optimal B, A, times, C the worst; score:B the best, followed by A, C, the worst.4Conclusion4.1ROD patients with evidence of climate change in line with the trends in the development of the disease law, along with dialysis age and duration of the louder, the yin and yang, phlegm and blood stagnation syndrome is most common that they, and the vacuity of renal osteodystrophy, false is mixed diseasemachine characteristics consistent.4.2Primary disease for patients with chronic nephritis ROD common deficiency of both yin and yang, the primary disease is more common yin deficiency and yin and yang deficiency in the diabetic patient population, Yang less card in the primary disease for patients with hypertension designate no significant difference in the distribution of its distribution characteristics to consider with all the original certificates of onset and pathogenesis characteristics can be used as a reference for TCM syndrome differentiation.4.3Primary disease was chronic glomerulonephritis in patients with dialysis age longer, and relatively long survival time in patients with diabetic nephropathy, dialysis age shorter survival time is relatively short.4.4Quality score of the yin and yang deficiency patients with regard to physical health of each to survive the worst; in the quality of life in mental health, the Yin Deficiency ideal yang type, followed by the yin and yang type worst, kidney-bone law of development of disease pathogenesis, but the yin deficiency type than yang and mental health ideal may yang type in patients with spleen and kidney yang pathogenesis characteristics, the above rules to check against the treatment of Chinese medicine early intervention provides a basis to improve the quality of life in patients.4.5The worst quality of life in patients with dialysis age greater than72months with regard to physical health, dialysis age36to72months and patients with less than36months of the worst; quality of life in mental health dialysis aged36to72months in patients with the best, followed by less than36months, the worst of greater than72months.更多还原