【作者】 盖银玲；

【导师】 许庆友；

【作者基本信息】 河北医科大学 ， 中西医结合临床， 2008， 硕士

【摘要】 络病理论是中医理论体系中的一个重要组成部分,其蕴藏着深刻的理论内涵。春秋战国时期的《黄帝内经》首次提出络脉的概念,初步论述了络脉的循行、生理及病理,为络病理论奠定了基础。汉代张仲景进一步发展了络病理论,他论述了部分络脉病证及与络脉有关病证的病机、诊法和方药。至清代,叶天士在《临证指南医案》中明确提出“久病入络”、“久痛入络”,强调“初为气结在经,久则血伤入络”,总结出较为完整的络病辨治理法,从而发展了前人的学术成果,使络病理论初成体系。至现代,络病理论得到充分重视,日益完善。深入分析络脉的生理病理机制,分析络病发生的原因,对于诊治慢性肾病有重要临床价值。目的:理论方面:搜集整理历代医家络病有关论述及当代关于络病文献,探讨络病学说的形成与发展;进而结合肾脏的生理及病理特点,应用络病学说探讨慢性肾病的中医病机,阐述肾络理论,研制出中药复方肾络通。临床方面:观察中药复方肾络通对系膜增生性肾小球肾炎(MsPGN)患者的肾脏保护作用,探讨其对MsPGN的肾脏保护作用及相关机制,为络病学说诊治慢性肾病提供临床依据,反证肾络通组方的科学性,进一步佐证络病学说的科学价值。方法:1理论探讨:在搜集整理历代医家络病有关论述及当代关于络病文献的基础上,探讨络病学说的形成与发展,进而结合肾脏的生理、病理特点慢性肾病临床表现,活血化瘀药治疗肾脏病的疗效等,探讨慢性肾病中医病因病机,指出其病因病机多为气虚、血瘀、络阻。确立“益气通络、活血化瘀”的治法,并据此制定中药复方肾络通。2临床研究:参照1985年9月中华肾脏病学会全国第二次肾脏病学术会议肾脏病协作组确定的《关于原发性肾小球疾病的病理类型及命名的建议》,我们选择了178例经肾穿刺确诊为系膜增生性肾小球肾炎患者,随机分为肾络通治疗组104例和雷公藤多甙对照组74例,肾络通组给以肾络通(黄芪30g,丹参15g,川芎10g,乌梢蛇10g,地龙12g,茯苓15g)或肾络通胶囊(每次4粒,日3次)口服,并根据临床症状加减用药,如血尿加侧柏叶,大、小蓟,茜草,花蕊石;气虚加党参、太子参等。45天为一疗程,观察2个疗程。对照组给以雷公藤多甙片(湖南省株洲市制药厂),每日公斤体重1毫克,分3次服用。进行对比观察。1985年第二次全国中医肾病会议制定的疗效判定标准分为:(1)完全缓解:症状体征消失,尿蛋白定量<0.2g /24h,肾功能、血脂恢复正常,尿红细胞不超过0-3个/HP;(2)基本缓解:症状体征消失,尿蛋白定量<lg/24h,尿红细胞少许至(+);(3)部分缓解:症状体征好转,实验室检查有好转,但未达到基本缓解的标准;(4)无效:用本法治疗2个月以上,症状体征和实验室检查均无好转或病情恶化。并根据此标准对两组患者的疗效进行判定。结果:临床研究表明,肾络通能明显改善MsPGN患者的主要症状、治疗组104例中完全缓解25例(24%),基本缓解47例(45%),部分缓解14例(13%),无效18例(17%),总有效86例(83%)。对照组完全缓解14例(19%),基本缓解17例(23%),部分缓解12例(16%),无效31例(41%),总有效43例(58%)。完全缓解率和总有效率与对照组相比有显著性差异。具体指标显示:1 24h尿蛋白定量治疗前与治疗后相比p<0.05,治疗组与对照组治疗后相比p<0.05,有显著性差异。2尿红细胞计数治疗前与治疗后相比p<0.05,治疗组与对照组治疗后相比p<0.05,有显著性差异。3尿β2-MG治疗前与治疗后相比p<0.05,治疗组与对照组治疗后相比p<0.05,有显著性差异。4仅血β2-MG,同组治疗前后相比p>0.05,治疗组与对照组治疗后相比p>0.05,无显著性差异。结论:1首先运用络病学说探讨慢性肾病的中医病机,指出慢性肾病是在肾脏病变日久,由于肾气亏虚、络脉瘀阻、终至络息成积的结果,其络息成积的病理基础与MsPGN肾脏ECM成分及其调控机制具有内在相关性。确立“益气通络、活血化瘀”的治法并据此制定肾络通组方,具有理论创新性。2肾络通具有益气通络、活血化瘀的功效,是治疗系膜增生性肾小球肾炎的有效方药。本研究从临床角度已证实肾络通具有降低尿蛋白,降低尿红细胞、尿β2-MG的作用。更多还原

【Abstract】 Collateral disease theory is an important part of the traditional Chinese medicine. Inner Canon of Huangdi had firstly offered the concept of collaterals. It has discussed collaterals distribution、physiology and pathology. It has settled the foundation for collateral disease theory. Zhang Zhongjing developed collateral disease theory furtherly, He has expounded a part of collateral disease and pathogenesis、technique of diagnosis、prescription of some disease concerned with collaterals. In Qing Dynasty, the book of《Linzheng zhinanyian》introduced“protracted disease intruding into collateral”、”protracted pain intruding into collateral”definitely, emphasized that Initial disease“Qi”stagnated in“Jing”and protracted disease blood wound intruded into collateral. It has summaried that the theory and methods of discriminate and treat collateral disease fairly complete, thus developed the scholarship of the ancients well, making the theory a system firstly. And nowadays, we pay more attention to the theory of collaterals disease, making it more perfect day and day. We analyzed the pathological mechanism of collaterals and the reason why collateral disease happens, then gave clinical importance to the treatment of chronic nephropathy. Objective: Study of theory, in order to approach the form and the development of the collaterals disease, we collect and arrange the collaterals disease treatment of the doctors’during past dynasties and the present age; next we combine together the physiology and pathology of the kidney to use collateral disease theory to approach the traditional Chinese medical pathogenesis, and then manufacture the traditional Chinese medical compound recipe called“Shenluotong”.Clinical study: In order to provide clinical proof which is used to treat the chronic nephrosis, we observe the protective action of the collateral disease theory which is used to the patients who are suffering the mesangial proliferative glomerulonephritis (MsPGN), and probe the protection and the correlative mechanism of the“MsPGN”, We also disprove the nature of science in the composed of shenluotong to move forward a single step the value of the collaterals disease theory.Method: 1 Probing the theory: On the base of compiling and sorting the collaterals disease treatment of doctors, during past dynaties and the present age. We approach the form and the development of collaterals disease, and then integrate the clinical manifestation of the chronical nephrosis, pathological feature of the renal, and the nephrosis rapeutic effect which we use to treat the nephrosis. We also probe the etiopathogenisis and the pathogenisis of the chronic nephrosis, and point out that etiopathogenisis and the pathogenisis most likely can be seen are the deficiency of vital energy, blood stasis and rein locked. According to the methods which are benefiting vital energy and communicating vein, promoting blood flow, we formulate the traditional Chinese medical compound recipe called“Shenluotong”. 2 Clinical research: Referencing the《the proposition of the MsPGN pathological type and its name》in the second nephrological meeting in September 1985, we chose 178 patients who had been made a definite diagnosis through renal needle biopsy, and divided stochastically them into treating group that is 104 people and controlling group that is 74 people, we use“Shenluotong”or tripterygium glycosides to each of them.“Shengluotong”include Radix Astragali 30g、Salvia Miltrorrhiza 15g Szechwan Lovage Rhizome 10g、Zaocys 10g、Pheretima 12g、Poria 15g, capsules have been taken in the type of oral administration (4pills tid po) . We must plus or minus the medicine with the change of the patient’s condition. Every course of treatment is 45 days, we observed 2 courses, control group are given tripterygium glycosides which is made in zhuzhou pharmaceutical factory in Hubei province,and direction is 1mg/kg·d, tid po. We contrast and observe in this process.According to the second nationwide conference about assessing therapeutic effect in nephrosis of traditional Chinese medicine, its standards can be divided into:1 Complete remission: symptom and signs are both vanished, the quantitation of urine protein is less than 0.2g/24h, renal function and lipid are recovery to normal, red blood cell count in urine are not so many as 0-3 /HP.2 Essentially remission: symptom and signs are both vanished, the quantitation of urine protein is less than lg/24h, red blood cell count in urine is from a little to (+).3 Partially remission: symptom and signs are improved, the experimental examination is improved, but are under the standard of essentially remission.4 Ineffective: to cure a patient more than 2 month in this method, symptom, signs and the experimental examination do not improve or the condition aggravates.Use these standards to assess the two groups of the patients’therapeutic effect.Result:The clinical study showed that kidney rutosids could improve the cardinal symptoms of MsPGN patients. There were 25(24%) patients completed remission、47(45%) patients basic remission、14(19%) patients partial remission、18(17%) patients inefficacy, 86 (83%)patients total utility in the treatment group. There were 14(13%) patients completed remission、47(45%) patients basic remission、17(23%) patients partial remission、12(16%) patients inefficacy, 43(58%) patients total utility in the control group. The total remission rate and total effect rate compared between control group with treatment group had significant difference.Specific index showed:1 Compared to the prior treatment, the 24h urine protein quantitation decreased significantly after treatment (p<0.05). Compared treatment group with post-treatment of control group, the 24h urine protein quantitation also had significant difference (p<0.05).2 Compared to prior treatment, the urine red blood cell count decreased significantly after treatment (p<0.05). Compared treatment group with post-treatment of control group, the urine red blood cell count also had significant difference (p<0.05).3 Compared to prior treatment, the urineβ2-MG decreased significantly after treatment (p<0.05). Compared treatment group with post-treatment of control group, the urineβ2-MG also had significant difference (p<0.05).4 Compared prior treatment with post treatment only the bloodβ2-MG had no-significant difference (p>0.05), there was the same result compared treatment group with post-treatment of control group (p>0.05).Conclusion:1 Use collateral theory to discuss the pathogenesis of chronic nephropathy by Chinese traditional medicine first, point out that chronic nephropathy is the consequence of kidney-Qi deficiency and collaterals lock and accumulation in final when nephropathy exist a long time, which pathology theory have internality pertinence with ECM in MsPGN and regulate mechanism. Establish the theory of benefiting vital energy with dredge collaterals and activating blood circulation to dissipate blood stasis, and to formulate schema on these ground will bring new ideas.2“Shenluotong”has efficacy of benefiting vital energy with dredge collaterals and activating blood circulation to dissipate blood stasis, is an available medicine to treat mesangial proliferative glomerulonephritis. This research has confirmed that ShenLuoTong has the ability of degrade Urine protein and urin-akaryocyte and urin-β2-MG, more over, it can protect the renal function.更多还原