宋国维教授治疗小儿肾病综合征临床经验的整理与研究

【作者】 周永红；

【导师】 宋国维；

【作者基本信息】 广州中医药大学 ， 中医儿科学， 2002， 硕士

【摘要】 小儿肾病综合征(简称小儿肾综，Nephrotic Syndrome，NS)是小儿时期常见的肾脏疾病，是一组由多种原因引起的肾小球基底膜通透性增加，导致血浆内大量蛋白质从尿中丢失的临床综合征。临床上许多肾脏疾病都可导致肾病综合征，小儿时期绝大多数为原发性肾病综合征。目前在国内因为泌尿系统疾病而住院的患儿中，发病率仅次于急性肾炎，严重影响到小儿的生长发育和身体健康。现代医学对于小儿肾综的发病机制研究较为深入，但是治疗上尚未见到明显的进展，激素和免疫抑制剂的治疗已经成为共识，许多新的药物正在研制或已投入临床。 祖国医学中，将本病归入“小儿水肿”“小儿水气”的范畴，认为其病因病机主要是肺脾肾三脏功能失调，水液代谢失常，泛溢于肌表所致。临床上有从肺论治，从脾论治的不同见解，也有根据病情的不同阶段分为脾虚湿重、脾肾阳虚、阴虚阳亢等类型来分型论治，同时，中西医结合治疗小儿肾综的研究热潮正旺，在应用西药的基础上运用中医中药治疗，不仅可以减轻激素的副作用，还可以很好地促进药效的发挥。 但是在近20年来的大量医学资料中鲜有人具体针对小儿生理、病理特点，完整地提出活血、益气、清热、利水四位一体的完整治疗体系，作为治疗小儿肾综的指导原则。宋国维教授在三十多年的临床实践中，经过了大量的临床验证，形成了个人独特的理论体系，提出：以活血为主，辨证施用益气、行水、清热的方法，来治疗小儿肾综。这套理论体系不仅取得了很好的临床效果，而且经过徐大基、刘文杰、章文平以及梁辉等运用科研方法对益气、活血、行水几方面在动物实验及临床试验中进行了验证，本文还要从清热活血的角度进一步研究，并将此观点与以上观点相合，完整的总结宋教授治疗小儿肾综的基本治疗思想，以更好的推广、应用于临床。 本研究旨在通过临床及实验研究对于这一理论体系进行系统总结，对其疗效进行严格验证，对其作用机理进行初步探讨。 在这一基本治疗体系中强调以“活血”为治疗关键，在此基础上辨证施用益气、行水、清热等方法。并对此进行了一系列临床及实验研究： 1994年徐大基先在阿霉素诱发的大鼠肾病模型上进行了实验，提出肾病模型大鼠普遍存在高凝状态，而且在临床实验中也得到类似结果，并认为高凝状态是肾病“瘀血”的微观指标，提示在小儿肾综的整个治疗过程中，不论是属于中医任何分型只要存在高凝状态均需自始至终的贯彻活血化瘀的重要治则。 96年刘文杰结合临床及实验观察，论证了活血化瘀的中药可以显著改善肾综患儿存在的高凝状态，能显著降低血清胆固醇、甘油三酯和提高高密度脂蛋白。 97年章文平运用益气活血剂治疗小儿肾综，临床及实验观察显示：益气活血剂可降低普遍存在的高凝状态，对抗氧自由基的损伤，大大减轻对于肾脏的不利因素； 广州中医药大学学位论文同时可以提高整体疗效、减少复发或反复。 2000年梁辉继续论证了在活血的基础上加强利水的疗效，证实行水活血方具有改善肾综患儿的血液流变学和降低血内皮素的作用。 2002年周永红运用先进的分子生物学技术，证实了清热活血方在改善症状、减少复发方面的显著疗效，并证实了ACE基因的l／D多态性与小儿肾综的疗效具有相关性。 由此，我们认为这一治疗体系在小儿肾综领域有着很高的学术价值及广阔的发展前景，对于中西医结合治疗小儿肾综将会产生积极而深远的影响。更多还原

【Abstract】 Nephrotic Syndrome (NS) is very common in renal diseases of childhood. The incident rate is increased recently and caused the worldwide attention. Most of doctors believe that high permeability of glomerular filtration caused the proteinuria, and the proteinuria is related to the nephrotic edema. And it is many renal diseases that lead to nephrotic syndrome, moreover, in childhood most of them is primary nephrotic syndrome. With time going by, new and deep treads in studies on pathogenesis of nephrotic syndrome appear, but scholars still can’t find the better therapy for the meatmen! The therapy of corticosteroid is the common prevention of nephrotic syndrome, and immunosuppressant is popular treatment with steroid-resistant nephrotic syndrome all around the world, doctors also developed some new medicine for the patients.According to the theory of TCM, the etiology and pathology of the disease is that nephrotic syndrome is developed by the external evils because of the usual basis and the deficiency of the lung, spleen and kidney. The main pathology is the unbalance of lung, spleen and kidney due to the stagnation of dampness. Based on the syndrome differentiation, the therapeutic principle may be warming of the kidney with strengthening spleen, or clearing of heat with discharging of damp. Furthermore, many physicians believe that the TCM combined with western medicine (WM) is a better therapy for the treatment of nephrotic syndrome, but how to elaborate the superiority of both TCM and WM so as to increased the curative effect and improve the life quality is an important topic worth of further study.Famous physician Song Guowei’s experience on the treatment of nephrotic syndrome is original. He proposed that the treatment should aim at activating of blood circulation, and based on the activating, the therapeutic principle may be clearing heat, replenishing qi and promoting water flow. Satisfactory effect may be obtained by application of prescription and drugs according to different pathogenesis.The research mainly focus on the clinical effect of Song’s theory for nephrotic syndrome through the experience on the clinic and laboratory and try to find out the mechanism of the childhood nephrotic syndrome.Under song’s guide, the research is concluded by his five post-graduate students after 8 years, hi 1994,Xu Daji used the adriamycin(ADR)-induced nephropathy rats as the animal model, and he concluded that the hypercoagulable state is common in the nephropathy rats. And from the clinical research he also suggested that the doctors should regard thehypercoagulable state as the sign of "stagnation of blood", and should use the principle of removing blood in treatment all the time.In 1996, during experiment Liu Wenjie got the result that the herbs of activating blood circulation could induce the hypercoagulable state and reduce urine protein and serum cholesterol and increase serum albumin level.Zhang Wenping did both clinical study and experimental study in 1997, respectively, he got the conclusion that replenishing qi and promoting blood flow herbs could decrease the high blood viscosity of nephrotic syndrome and resist the damage of oxygen free radical.In 2000, after research Liang Hui proposed that the result of experiment showed that activating water and blood circulation decoction could improve indexes of blood rheology, reduce serum ET and lighten pathologic changes of kidney.2 years later, Zhou Yonghong investigated the correlation between angiotensin I converting enzyme(ACE) gene polymorphism and the treatment of clearing heat and activating blood in childhood nephrotic syndrome. The conclusion is that Genotype DD is associated with poor responsiveness to the therapy in NS children, respectively, Genotype II and Genotype ID is related to high responsiveness. And the treatment can reduce 24-hours urinary protein effectively,Finally, Song’s theory is very valuable for the treatment of childhood nephrotic syndrome. So it is very important for every pediatrician to learn and de更多还原