从气血水论治特发性膜性肾病及乙酰肝素酶与IMN尿蛋白相关性的研究

【作者】 赵琛；

【导师】 占永立；

【作者基本信息】 北京中医药大学 ， 中西医结合临床医学， 2012， 硕士

【摘要】 特发性膜性肾病(IMN)是原发性肾小球疾病的重要病理类型,随着肾脏病理活检技术的推广应用,该疾病的确诊率逐年提高,其治疗方法也广受关注。西医对于该病的治疗虽有一定经验,但是使用免疫抑制剂后的安全性及有效性仍值得商榷。导师在深入研究祖国传统医学理论基础上,结合临床实践经验,认为IMN的发生主要在于气血水三者的失调,其核心病机在于气虚血瘀水停,故而创立了以益气活血利水法为主的治疗特发性膜性肾病的方法。本临床研究主要探讨从气血水论治IMN的治疗特色和优势。乙酰肝素酶作为一种新近得到广泛关注的葡糖核苷内切酶,其在体内具有多项生物学功能；一些研究表明其表达可能与肾脏疾病有关。本课题的实验研究主要探讨乙酰肝素酶与特发性膜性肾病的尿蛋白之间的相关性,为今后进一步探讨中药减轻特发膜性肾病尿蛋白的作用机制奠定基础。研究一：益气活血利水法治疗特发性膜性肾病的临床研究目的：以中医气血水理论为指导,观察益气活血利水法治疗特发性膜性肾病的临床疗效。方法：本研究采用随机、开放、对照的临床试验方法,将符合病例纳入标准的60例患者按就诊时间顺序随机分组为试验组(基础治疗+益气活血利水方药)和对照组[基础治疗+血管紧张素转化酶抑制剂(ACEI)],比较两组患者治疗前后以及两组间的中医证候疗效、疾病综合疗效、尿蛋白及其它相关理化指标的变化,初步评价益气活血利水法治疗特发膜性肾病的临床疗效。以SPSS17.0建立数据库并进行统计学分析,认为P值≤0.05表示有统计学意义。结果：1.整体疗效的分析：在对60例入组病例进行分析后得出①中医证候疗效评价：试验组总有效率88.6%,对照组总有效率88%；②西医综合疗效评价：试验组总有效率85.7%,对照组总有效率80%；③主要理化指标比较：在治疗前后的组内比较上,试验组和对照组患者治疗前后的Scr、BUN、ALB、24小时尿蛋白定量以及eGFR的指标变化均具有显著的统计学差异(P<0.05)；两组各项指标在治疗前以及治疗后的组间比较上,差异均不具有统计学意义(P>0.05)。2.24小时尿蛋白定量的分层分析24小时尿蛋白定量小于3.5g患者组：①中医证候疗效评价：试验组总有效率88.5%,对照组总有效率91.7%；②西医综合疗效评价：试验组总有效率80.7%,对照组总有效率83.3%；③主要理化指标比较：在治疗前后的组内比较上,试验组和对照组患者治疗前后的Scr、BUN、ALB及eGFR的指标变化均具有显著的统计学差异(P<0.05)；两组各项指标在治疗前以及治疗后的组间比较上,差异均不具有统计学意义(P>0.05)。24小时尿蛋白定量大于3.5g患者组：①中医证候疗效评价：试验组总有效率88.9%,对照组总有效率84.6%；②西医综合疗效评价：试验组总有效率100%,对照组总有效率76.9%。③主要理化指标比较：在治疗前后的组内比较上,试验组和对照组患者治疗前后的Scr、ALB、eGFR及24小时尿蛋白定量的指标变化均具有显著的统计学差异(P<0.05)；两组各项指标在治疗前以及治疗后的组间比较上,差异均不具有统计学意义(P>0.05)。3.影响疗效的相关因素的分析：疗前的肾功能指标(Scr、BUN),24小时尿蛋白定量,ALB, APTT以及eGFR与疗效间存在显著的相关性(P<0.05)；疗程对疗效的影响差异具有显著的统计学意义(P<0.05),治疗4个月及更长疗程时,患者疗效较明显；而性别、年龄及病理分期等对疗效的影响差异无统计学意义(P>0.05)。结论：1.从中医病机理论分析,特发性膜性肾病的中医病机责之于气血水三者的失调,气虚、血瘀、水停可能是特发性膜性肾病的核心病机。2.益气活血利水法具有较好的缓解特发性膜性肾病的中医症状、减轻尿蛋白的作用,其疗效与血管紧张素转换酶抑制剂相当。3.理化指标与疗效的相关性分析结果提示：疗前的肾功能指标(Scr、BUN),24小时尿蛋白定量,ALB, APTT以及eGFR等指标对治疗效果均可产生一定的影响；疗程与疗效显著相关,长疗程时患者疗效较明显；而性别、年龄及病理分期等对疗效无明显影响。研究二：乙酰肝素酶与特发性膜性肾病患者尿蛋白相关性的实验研究目的：通过对特发性膜性肾病患者及健康人群的外周血中乙酰肝素酶含量的检测,并将其与24小时尿蛋白定量进行比较分析,初步探索乙酰肝素酶与尿蛋白之间的相互关系,为今后进一步探讨中药减轻特发膜性肾病尿蛋白的作用机制奠定基础。方法：本研究中共采集血样48例,其中特发性膜性肾病患者33例,根据患者的24小时尿蛋白定量的含量将其分为缓解组(24小时尿蛋白定量小于1.5g/24h)17例和未缓解组(24小时尿蛋白定量≥1.5g/24h)16例,并采集健康人群(24小时尿蛋白定量均小于200mg/24h)15例血样,用人乙酰肝素酶(HPA)酶联免疫分析(ELISA)试剂盒测定样本的乙酰肝素酶含量,并与入组病例的24小时尿蛋白定量进行比较,以SPSS17.0建立数据库并进行统计学分析,认为P值≤0.05表示有统计学意义。结果：对研究病例的分析表明：①缓解组、未缓解组和健康人群在24小时尿蛋白定量和乙酰肝素酶含量的组间比较上差异有统计学意义(P<0.05)；且乙酰肝素酶的含量随24小时尿蛋白定量的不同而表现出显著差异,24小时尿蛋白定量较高的未缓解组,乙酰肝素酶的含量也较高。②经对入组数据的Pearson相关性分析得出,乙酰肝素酶含量与24小时尿蛋白定量之间存在着显著的线性相关。③经SPSS17.0统计软件对数据进行分析后,模拟出乙酰肝素酶含量与24小时尿蛋白定量直线回归的方程式：Y=88.561+6.357X。结论：本研究结果显示,在特发性膜性肾病患者与健康人群对比的外周血乙酰肝素酶含量和24小时尿蛋白定量的相关性分析中,发现外周血乙酰肝素酶含量与24小时尿蛋白定量存在显著的线性相关。更多还原

【Abstract】 Idiopathic membranous nephropathy (IMN) is an important pathological ty pe of glomerular disease, along with the popularization and application of the technology, the disease diagnosis rates were increased year by year. There is also a widespread concern about the IMN’s treatment. Western medicine treatment for the disease has certain experience, but safety and effectiveness of the use of immunosuppressive agents are still debatable. Mentors in the in-depth study of traditional Chinese medical theory, combi ned with clinical experience, argued that this disease mainly lies in the dis orders of Qi Xue and Shui, due to Qi deficiency, blood stasis and water s tagnation, he founded the Yiqi Huoxue Lishui method to treat the disease of idiopathic membranous nephropathy. The clinical study mainly discusse d the characteristics and advantages of Yiqi Huoxue Lishui methods in tre ating IMN.Heparanase is a new glucose nucleosides enzyme which received extensi ve attention in these years, it has many biological functions; some studies show that its expression may be associated with renal disease. In this ex perimental study, we paid attention to the correlation of the heparanase and the urinary protein in the idiopathic membranous nephropathy patient s, to lay the foundation for the further study of the herbal curative effect f or relief the urinary protein in the idiopathic membranous nephropathy pati ents.Part1:The effect of Yiqi Huoxue Lishui therapy for treating the dise ase of idiopathic membranous nephropathyObjective:As the guide of QiXueShui theories of TCM, we observed the effects of Yiqi Huoxue Lishui therapy for treating IMN.Methods:This study used a randomized, open, controlled clinical trials,60patients that conformed to the case inclusion criteria were randomly divi ded into experimental group (basic therapy+Yiqi Huoxue Lishui herbs) a nd control group (basic therapy+ACEI) according to the time sequence. We compared with two groups patients before and after treatment as wel l as among two groups of TCM efficacy, disease comprehensive curative effect, urinary protein and other related physical and biochemical index ch ange.Preliminary evaluation the effects of Yiqi Huoxue Lishui therapy for tr eating IMN. We used SPSS17.0to establish database and analyzed statis tically, that P value<0.05indicated the statistical significance.Results:1. Total efficacy analysis:The results of the60cases indicated:①TCM ef ficacy evaluation:the total effective rate of the experimental group was88.6%, the total effective rate of the control group was88%;②The western medicine comprehensive effectiveness evaluation:the total effective rate of the experimental group was85.7%, the total effective rate of the control group was80%;③The main physicochemical index:In the comparison wit hin groups, two groups of patients before and after the treatment, Scr, BU N, ALB,24hUpro and eGFR index changes had statistical significance(P <0.05); In the comparison between groups, two groups of patients befor e and after the treatment, all of the index changes had no statistical signif icance(P>0.05).2. The further analysis for the different groups according to the24hUpro. The group of the patients that24hUpro was less than3.5g:①TCM efficac y evaluation:the total effective rate of the experimental group was88.5%, the total effective rate of the control group was91.7%;②The western m edicine comprehensive effectiveness evaluation:the total effective rate of t he experimental group was80.7%, the total effective rate of the control gr oup was83.3%;③The main physicochemical index:In the comparison wit hin groups, two groups of patients before and after the treatment, Scr, BU N, ALB and eGFR index changes had statistical significance (P<0.05); I n the comparison between groups, two groups of patients before and after the treatment, all of the index changes had no statistical significance(P>0.05).The group of the patients that24hUpro was more than3.5g:①TCM effica cy evaluation:the total effective rate of the experimental group was88.9%, the total effective rate of the control group was84.6%;②The western me dicine comprehensive effectiveness evaluation:the total effective rate of th e experimental group was100%, the total effective rate of the control gro up was76.9%;③The main physicochemical index:In the comparison with in groups, two groups of patients before and after the treatment, Scr, ALB, 24hUpro and eGFR index changes had statistical significance (P<0.05); In the comparison between groups, two groups of patients before and a fter the treatment, all of the index changes had no statistical significance(P>0.05).3. Analysis for the related factors that influenced the curative effect:the in fluences differences of the renal function indexes (Scr, BUN),24hUpro,a lbumin, APTT and eGFR index for the effects had statistical significance (P<0.05); the influences differences of the course of treatment with the cl inical effects had statistical significance(P<0.05), as the treatment for4months and longer course, the curative effcts were more obvious; the inf luences differences of gender, age and pathologic stage for curative effect s did not have statistical significance (P>0.05).Conclusion:1. From the TCM theory analysis, TCM pathogenesis of idiopathic membr anous nephropathy is the disorders of Qi, blood and water, Qi deficiency with blood stasis and water stagnation may be the main type of the patho genesis.2. The Yiqi Huoxue Lishui therapy can relief the TCM symptoms, reduceth e urinary protein effectively for the patients of IMN, the clinical effects of Yiqi Huoxue Lishui therapy are almost as same as the functions of ACE I.3. The related factors, such as the renal function indexes (Scr, BUN),24hUpro, albumin, APTT and eGFR can produce certain influence on the clinical effect. The treatment course has certain influence on the curative effect, as the course is longer, the effect is more obvious. However, gen der, age and pathologic stage do not have certain influence on the clinical effect.Part2:The experimental research for the relationship between the h eparanase and the urinary protein of the idiopathic membranous nep hropathy patientsObjective:Detect and analyze the quantity of HPA in the blood of IMN p atience and healthy persons, found the relationships between the urinary protein and the heparanase, to lay the foundation for the further study of t he mechanism of herbal function for relieving the urinary protein of the pa tients of IMN.Methods:The study collected48patients, including33patients of idiopat hic membranous nephropathy,17patients were divided into clinical remissi on group (24hUpro was less than1.5g/24h) according to the24hUpro, also,16cases were divided into not mission group (24hUpro was more th an or equal to1.5g/24h). We also detected the HPA of15healthy per sons (24hUpro was less than200mg/24h).We used the human hepara nase (HPA) enzyme immunoassay (ELISA) kit for the determination of sample of heparanase level, and compared with the24hUpro of the cases. We used SPSS17.0to set up database for statistical analysis, The P val ue<0.05indicated a statistical significance.Results:The case study analysis showed that:①In the comparison betw een groups, the difference of the HPA quantity and the24hUpro in the re mission group, not remission group and healthy persons had statistical sig nificance (P<0.05). The difference through the HPA quantity with the24h Upro showed significant differences, in the not remission group, as the hig her level of24hUpro, the expression of heparanase level was higher than the remission one.②The group of data by Pearson correlation analysis s howed that, heparanase quantity and24hUpro had significant linear correl ation.③The SPSS17.0statistical software for data analysis simulated sim ulation chart of the linear regression equation of the heparanase quantity and24hUpro:Y=88.561+6.357X.Conclusion:This study indicates:In the analysis of the relationship betwe en the HPA quantity in the peripheral blood and the24hUpro in idiopathic membranous nephropathy patients, we find that the HPA quantity and the24hUpro have a significant linear correlation.更多还原