【作者】 张林；

【导师】 檀金川；

【作者基本信息】 河北医科大学 ， 中医内科学， 2012， 硕士

【摘要】 目的：血液透析是治疗终末期肾病的主要替代疗法之一，营养不良是终末期肾病(ESRD)长期血液透析治疗的患者常见的重要并发症。经研究表明，营养不良在维持性血液透析(maintenance hemo dialysis,MHD)患者中发病率为23%～76%，其中约6%～8%严重营养不良〔1-2〕，严重营养不良增加了MHD患者的住院率和死亡率，严重影响了患者的生活质量。营养不良的患者不仅免疫功能降低，贫血加重，还常常发生感染、心脑血管疾病等严重的并发症，如何提高MHD患者的生活质量及长期存活率，今后将是肾内科医师面临的巨大挑战。因此，积极有效地防止和纠正维持性血液透析患者的营养不良，是提高维持性血液透析患者生活质量、降低病死率的重要措施。维持性血液透析患者营养不良与尿毒症所致的蛋白质摄入量不足、代谢和内分泌紊乱、消化系统症状、血清瘦素水平增高、持续存在的代谢性酸中毒、炎症反应等因素有关，从目前的相关研究中可得知，配合中药治疗对改善维持性血液透析患者营养不良的症状有一定疗效，且相对廉价，有重要的研究价值和广泛的应用前景，因此从中医药领域中寻找新的突破点具有重大意义，前景十分广阔。健脾益肾、和胃降浊方是导师根据本病的中医病机特点而创立的，初步临床观察有明显疗效。本课题目的在于通过详细、完整的临床观察来明确其疗效，推测其可能的作用机理。为临床上治疗维持性血液透析患者营养不良，开创一个新的思路。方法：观察维持性血液透析患者60例，随机分为两组，对照组给予规律血液透析及对症治疗，但不予中药治疗。治疗组口服健脾益肾、和胃降浊方（基本方：党参12g、黄芪20g、白术15g、陈皮12g、当归12g、土茯苓15g、砂仁12g、大黄9g、丹参15g等）。加减：气虚加山药、扁豆；阴虚加熟地、龟板；阳虚加肉苁蓉、杜仲、菟丝子；阴阳两虚加山茱萸、肉桂、干姜；气阴两虚加枸杞子、黄精、女贞子。每日一剂，水煎服，三个月为一个疗程，观察两个疗程。两组患者均给予规律血液透析，3次/周，重组促红细胞生成素(EPO)3000U/次,皮下注射，2次/周。优质蛋白饮食及其它对症支持治疗。两组病例在性别、年龄、体重、原发病、病程、HD时间差异无统计学意义(P>0.05)，具有可比性。观察两组患者治疗前后超敏C反应蛋白(hs-CRP)、血清白蛋白（Alb）、血清前白蛋白(PA)、内源性人红细胞生成素(EPO)、血红蛋白(Hgb)、红细胞压积(Hct)、残余肾功能(RRF)、尿素氮(Bun)、血肌酐(Scr)、营养不良评分、中医症状评分的变化，并做出疗效评价。结果：1用药24周后治疗组与对照组患者中医症状积分均比用药前明显减少，但治疗组的中医症状积分减少十分显著(p<0.01)，治疗后治疗组与对照组间比较有显著性差异(p<0.01)。治疗组治疗后患者营养状态主观评分有十分明显地提高(p<0.01)，对照组治疗前后积分无明显改变(p>0.05)。由图表1中可见治疗组营养不良治疗后中医症状明显好转，疗效显著优于对照组。2两组患者用药前Alb、PA水平无显著性差异(P>0.05)。治疗24周后对照组Alb、PA较治疗前无明显变化(P>0.05)，但治疗组Alb、PA较治疗前明显上升(P<0.05)，治疗组疗效明显优于对照组。表明治疗组改善维持性血液透析患者营养指标方面好于对照组。治疗组和对照组用药前hs-CRP水平间无显著性差异(P>0.05)。治疗24周后治疗组与对照组hs-CRP同时较用药前下降(P<0.01)，但治疗组和对照组间有显著性差异(P<0.01)，治疗组明显低于对照组。表明治疗组改善维持性血液透析患者微炎症状态作用优于对照组。两组患者用药前Hgb、HCt水平间无显著性差异(P>0.05)。治疗24周后治疗组与对照组Hgb、HCt同时较用药前上升(P<0.01)，但治疗组和对照组间有显著性差异(P<0.01)，治疗组明显高于对照组。表明治疗组改善贫血作用优于对照组。由图表可见对照组治疗24周后BUN、Scr都较治疗前有所下降，但是和治疗前相比较无显著性差异(p>0.05)；治疗组患者治疗24周后BUN、Scr较治疗前下降，和对照组比较无显著性差异(p>0.05)；治疗组和对照组治疗24周后RRF均有所下降，但对照组患者RRF较治疗组下降明显，两组患者比较有显著性差异(p<0.05)。说明治疗组在延缓维持性血液透析患者残余肾功能方面优于对照组。治疗前治疗组和对照组之间血清EPO水平无显著性差异(P>0.05)。治疗24周后，对照组血清EPO水平较用药前无明显好转(P>0.05)，治疗组患者血清EPO水平较治疗前明显提高。和对照组血清EPO水平比较有显著性差异(P<0.01)。表明经治疗后，治疗组可明显提高血液中EPO含量。结论：1健脾益肾、和胃降浊方能明显改善MHD患者营养不良的临床症状和体征积分，使患者的生活质量明显提高。2健脾益肾、和胃降浊方能够提高Alb、PA水平，改善MHD患者的营养不良状态；可以降低hs-CRP的水平，可以有效地控制维持性血液透析患者的微炎症状态；可以促进内源性人红细胞生成素的分泌，提高血清EPO的水平。3健脾益肾、和胃降浊方能提高Hgb、Hct水平；降低Bun、Scr，纠正患者的贫血，可以延缓长期血透患者的残余肾功能的下降。4健脾益肾、和胃降浊方是以具有补虚扶正、解毒降浊、活血化瘀功效的中药组方而成，体现了中医扶正与祛邪同施，标本兼治的整体性原则，具有疗效确切、副作用少、价格低廉等优点，有广泛的临床应用价值。更多还原

【Abstract】 Objective: Blood dialysis is the treatment of end-stage renal diseasemainly one of alternative therapies, malnutrition is end-stage renal disease(ESRD) keep the blood dialysis patients common major complications. Thestudy showed that malnutrition on maintenance hemodialysis(maintenancehemodialysis, MHD) in patients with rate was23%~76%, ofwhich about6%~8%severe malnutrition (1-2), severe malnutrition increasesthe maintenance hemodialysis patients to be hospitalized and mortality,serious impact on the quality of life of the patients. Malnutrition patients notonly reduce the immune function, anemia aggravating, often happen infection,disease of heart head blood-vessel, serious complications, maintenancehemodialysis, how to improve the quality of life of the patients and long-termsurvival rate, will in the future is renal physician’s challenge. Therefore, toeffectively prevent and corrective maintenance hemodialysis patientsmalnutrition, is to improve the quality of life of the patients maintenancehemodialysis, reduce the mortality of important measures. Maintenancehemodialysis patients with malnutrition caused by insufficient intake ofprotein uremia, metabolic and endocrine disorder, digestive system symptoms,blood lean meat increased levels, persistent metabolic acidosis, inflammatoryreaction factors, from the current related study can be informed, with Chinesemedicine therapy to improve maintenance hemodialysis patients malnutritionsymptoms have certain curative effect, and relatively cheap, have importantresearch value and broad application prospect, so from a new breakthrough inthe field of medicine for has the great significance and prospect.The spleen and stomach drop benefiting kidney, turbidity party accordingto the traditional Chinese medicine is the mentor and the pathogenesis characteristics was founded, preliminary clinical observation have apparentcurative effect. This topic through detailed and complete aims to clinicalobservation of to make clear its curative effect, its possible that themechanism of action. For clinical treatment maintenance hemodialysispatients malnutrition, create a new train of thought.Method: Observe maintenance hemodialysis patients60cases wererandomly divided into two groups: control group given the high quality andhigh protein diet full HD, but not herbal treatment. The treatment groupbenefiting kidney, and oral invigorating spleen stomach drop turbidity party(basic party:12g, codonopsis pilosula astragalus20g, white atractylodes15g,poria cocos12g, dried tangerine or orange peel to12g, law12g, smilaxglabra roxb sprouting15g, sand benevolence12g, pogostemon patchouli12g, rhubarb9g, danshen15g, etc.). Add: deficiency and yam, lentils; Yindeficiency and cultivated land, newly cultivated land GuiBan; Yang, c.deserticola and eucommia, dodder; Yin and Yang added two empty dogwood,cinnamon, dry ginger; Yin deficiency of both qi and medlar, yellow fine,containing. A daily agent, each agent two Fried, each Fried200ml, blending,and sooner or later, temperature uniform, three months for a period oftreatment, observe two treatment. Two groups of patients were given lawhemodialysis, three times per week, the high quality protein diet and othersymptomatic treatment and support. Make two groups of patients in thegender, age, original disease, course and degree of malnutrition after statisticsprocessing has no significant difference (P>0.05), comparable. Two groupsof patients before and after treatment observation hypersensitivity c-reactiveprotein (hs-CRP), serum albumin (Alb), before the serum albumin (PA),endogenous human erythropoietin (EPO), the hemoglobin (Hgb), red bloodcell deposited (HCt), residual renal function (RRF), urea nitrogen (BUN),creatinine (Scr), poor nutrition rating, Chinese medicine the symptom scorechanges, and make curative effect evaluation. Results:1drug24weeks later the treatment group and control group patients TCMsymptoms than before the drug are integral significantly reduced, but thetreatment group of TCM symptoms integral reduce very significant (p <0.01),the treatment group and control group between was significant difference (p <0.01). Drug use24weeks later two groups of patients, nausea and vomitingclassification (0degrees+mild) is the number of medicine are the before havedeclined, but the treatment groups of patients, nausea and vomitingclassification (0degrees+mild) is the number of group compared with thesignificant difference. These data can explain the treatment group to improvedigestion system function disorder obvious effects. After the treatment grouppatients nutrition state subjective ratings have very improved obviously (p <0.01), and the control group integral no significant changes before and aftertreatment (p>0.05). The chart can be seen in treatment group of nutritionalstatus after improved obviously, curative effect is significantly better than thecontrol group.2the two groups of patients before drug Alb, PA level no significantdifference (P>0.05).24weeks after treatment group Alb, PA is no changebefore treatment (P>0.05), but the treatment group Alb, PA is beforetreatment significantly increased (P <0.05), the curative effect of treatmentgroup was better than control. Shows that the treatment group to improvemaintenance hemodialysis patients nutrition status in treatment group.Treatment group and control group before drug hs-CRP level no significantdifference between (P>0.05).24weeks after treatment in treatment groupand a drug hs-CRP before rising (P <0.01), but the treatment group andcontrol group between significant difference (P <0.01), the treatment groupwas significantly higher than the control group. Shows that the treatmentgroup to improve maintenance hemodialysis patients micro inflammationstatus effect than those in the control group. Two groups of patients beforedrug Hgb, HCt between level no significant difference (P>0.05).24weeksafter treatment in treatment group, HCt and a drug Hgb before rising (P <0.01), but the treatment group and control group between significant difference (P <0.01), the treatment group was significantly higher than thecontrol group. Shows that the treatment group than in control group action toimprove anemia. The chart shows the control group therapy24weeks laterBUN, Scr is before treatment has dropped, but before treatment comparedwith no significant difference (p>0.05); The treatment group were treated24weeks later BUN, Scr is before treatment decreased obviously (p <0.01), andthe control group was significant difference (p <0.01); The treatment groupand control group therapy24weeks later RRF all declined, but patients RRFtreatment group is down significantly, two groups of patients with significantdifference (p <0.05). Explain the treatment group in delaying maintenancehemodialysis patients residual kidney function better than control group.Before treatment between treatment group and control group serum level ofEPO no significant difference (P>0.05).24weeks after treatment, the controlgroup serum EPO before drug level is not improved significantly (P>0.05),the treatment group patients serum EPO before treatment level is improvedsignificantly. And the control group serum EPO to level with significantdifference (P <0.01). Shows that the treatment group in the blood canobviously increase content of EPO.Conclusion:1the spleen and stomach drop benefiting kidney, can obviously improve theturbidity maintenance hemodialysis patients malnutrition clinical symptomsand signs integral, make the patient’s quality of life improved obviously.2the spleen and stomach drop benefiting kidney, turbidity party can improveAlb, PA level, improve maintenance hemodialysis patients nutrition state; Canreduce the hs-CRP level, can effectively control maintenance hemodialysispatients micro inflammation of the state; Can promote endogenous humanerythropoietin secretion, improve the level of serum EPO; Reduce the Bun,Scr, reduce uremia toxins on maintenance hemodialysis patients malnutritioninhibitory effect. Speculation is that the treatment group than in control grouprole of the possible mechanism. 3spleen and stomach drop the kidney, can improve the turbidity Hgb, Hct,serum EPO and PA level. Reduce the Bun, Scr, improve patients with anemia,and renal function level, and slow down long-term hemodialysis patients onthe progress of the remnants of the kidney function.4the spleen and stomach drop benefiting kidney, turbidity party is have thevirtual centralizer, detoxification drop turbidity and remove blood stasisefficacy of traditional Chinese medicine formula and become, reflect Chinesemedicine centralizer and remove with evil, with the integrity of the specimenprinciple, and the application of erythropoietin, levorotatory carney, statinsal.growth hormone drugs such as compared, have definite effect, fewside-effects, price is low wait for an advantage, with extensive clinicalapplication value.更多还原