刘宝厚教授学术思想及从湿热论治肾病蛋白尿临证经验整理研究

发布时间：2018-01-03 03:04

本文关键词：刘宝厚教授学术思想及从湿热论治肾病蛋白尿临证经验整理研究　出处：《中国中医科学院》2016年博士论文　论文类型：学位论文

【摘要】：刘宝厚教授是国家人力资源与社会保障部、卫生与计划生育委员会、中医药管理局遴选的第五批全国老中医药专家学术经验继承指导老师。从事中西医医疗、教学和科研工作60余年,专注研究肾脏病40余年,是我国著名的中西医结合医学家和肾脏病学专家,在临床上积累了丰富的肾脏病治疗经验,形成了诸多独特的学术思想。本文广泛收集相关资料,系统整理刘宝厚教授学术思想,在综述了中医药治疗肾病蛋白尿及过敏性紫癜性肾炎的中医诊治研究进展基础上,对刘宝厚教授从湿热论治肾病蛋白尿临证经验进行了全面的总结,同时对以“湿热不除,蛋白难消”学术思想为指导的经验方清热健肾汤进行了前瞻性的随机对照临床研究,客观分析其临床疗效。力求使独具特色的理论见解、学术思想及临证经验得以传承和发扬,更好的为患者服务。第一部分文献综述从病因病机及中医辨证论治等方面进行综述中医药治疗肾病蛋白尿的研究进展,综述示目前中医对蛋白尿的病位病机认识渐趋一致,多数医家认为其总的病机为本虚标实,本虚以肺、脾、肾三脏为主,标实以寒、湿、热、瘀等病因为主,导致肾失封藏、水谷精微从尿液外流所致,且本虚与标实相互影响、互为因果,导致病久缠绵难愈。在肾病蛋白尿的治疗方面,现代医学仍感很棘手,多数中医专家从整体论治兼顾虚实,多以补益脾肾为主,针对不同外邪选用祛风、清热、除湿、化瘀等治则,可取得良好疗效,但都做到“祛邪勿伤正,补虚勿壅滞”。过敏性紫癜性肾炎(即紫癜性肾炎)是过敏性紫癜最严重的并发症,是目前临床常见疾病,其临床表现多样,可分为肾外表现和肾脏表现。最常见的临床表现是血尿、蛋白尿,紫癜性肾炎具有病情缠绵、反复发作的病理特点,肾损伤的发生及其损害程度直接决定该病的预后。现代医学对于其病因尚未明确,目前认为可能与感染和变态反应有关。从中医理论分析,不外乎正邪两端,邪实以风邪、水湿、热毒、瘀血等实邪为主,正虚则以肺脾肾三脏气虚及阴虚多见,脉络受损,血不循经,溢出脉外是其基本病机,其特点是本虚标实。西医对本病尚无特效治疗措施,中医药在该病的治疗方面有明显的优势,特别是在控制紫癜、蛋白尿、血尿以及改善患者过敏体质等方面卓有成效。具体治疗应进行辨病分期辨证治疗,首先分清急性活动期还是慢性迁延期。急性活动期以紫癜始发为主要特征,以标实为主,大致可分为血热妄行型、湿热内伏型、瘀血阻络型；慢性迁延期紫癜多已减少或消退,伴有肾脏损害,此时以正虚为主,为正虚邪恋之证,治疗当扶正祛邪并重,总以扶正不留邪,祛邪而不伤正为要。第二部分名老中医刘宝厚教授学术思想整理国家级名老中医刘宝厚教授在数十年的工作中,积累了丰富的肾脏病治疗经验,并形成了诸多独特的学术思想。他在学术思想上鼓励创新,本人特别勇于创新。他研究制订的“慢性肾小球肾炎中医辨证分型方案”,在1985年南京第二次全国中医肾脏病学术会议上采纳为全国试行方案,并由卫生部收入《中药新药临床研究指导原则》,对指导慢性肾炎的诊治起到了良好的效应。率先在国内将血液流变学检测运用于肾小球疾病血瘀证的诊断、中医辨证及疗效评估上,为肾脏病血瘀证的诊断建立了一种简便、易行的客观指标,其有关论文在国内被广泛引用。刘老师将肺肾之间的生理、病理联系,概括地称之为“肺肾相关理论”,以期能更准确地反映中医肺肾之间的内在联系,对阐明补肾法何以能防治肺系疾病提供理论依据,提出的“肺肾相关理论”在防治慢性阻塞性肺病上确有一定的指导意义。倡导分阶段论治,他认为同一疾病在不同阶段其病理机制也不同,因此在治疗时应按辨证分型进行治疗,此即同病异治,在他采取中西药有机结合分阶段治疗肾病综合征过程中最能体现这一学术思想。刘宝厚教授在临床中提出“中西医双重诊断,中西药有机结合”的临床医学模式,认为中西医结合是我国医学发展的必然趋势,中西医结合的关键在于找准“结合点”,标准是能否提高疗效,在诊断上采用中西医双重诊断,参照辨病辨证情况,在治疗上将中西药有机结合,优化组合,取长补短,提高疗效同时可减轻副作用。他在全面分析肾脏病病因病机基础上,结合大量的临床实践,提出肾脏病中医辨证论治的三大要领,即“祛邪务尽,扶正从缓”；“湿热不除,蛋白难消”；“瘀血不去,肾气难复”。刘宝厚教授提出“三焦学说”,认为三焦既不能看作有形之腑,也不能列入六腑之中。它是古人根据脏腑所处的人体部位划分了三个区域,用气化学说论述了三个区域内脏腑的生理功能,并使其整体化。所以,三焦实际上只是一个学说,是讲“气化作用”的学说。刘宝厚教授还提倡“辨证之要,位性合参”,把病位辨证与病性辨证有机结合起来,提出“病位病性辨证法”,这种辨证方法在诊治疾病过程中起到提纲挈领的作用,为初学中医者提供了简便易行的方法。第三部分刘宝厚教授从湿热论治肾病蛋白尿临证经验总结肾在中医脏腑学说中占有重要的地位,它不仅指解剖学上的肾脏,而且是一个生理功能相当广泛,与人体生殖、生长发育、水液代谢、神经、内分泌代谢等均有直接或间接关系的重要脏器。肾的作用重大而特殊,有主宰生命之概念。故历代医学家称“肾为先天之本”,“生命之根”。肾脏病中湿热形成的原因极其复杂,刘宝厚教授认为湿热的产生大概有以下两点：感受湿邪,体内生湿、二者相合,日久郁而化热,形成湿热之证；以及长期服用大量激素,日久抑真阳损真阴,使机体阴阳平衡失调,内生水湿,形成湿热之证。在肾脏病过程中,湿热伤肾,引起肾病病理改变,且往往贯穿肾病病程的终始,在病情进展的过程中起主导因素。临床发现感染是引起肾病加重和反复发作的主要原因,肾病病情迁延不愈,肾病患者易反复感染,这一点与湿热致病的特点相似,即病程较长及湿热蕴蒸缠绵难解的特点,湿热型肾病患者大多与继发性感染有关,尤其与一些隐性的感染病灶关联更为密切。蛋白尿是精微物质不能濡养机体反而从尿液中漏出所致,本虚标实为主要病机。刘宝厚教授认为在临床上蛋白尿难消,应特别重视感受实邪损伤的主要病理因素,实邪往往影响气机调畅,蕴结于体内会加重精微物质的漏出,致使蛋白尿患者反复发作、缠绵难愈。湿热之邪最缠绵难愈,在众多实邪之中最多见,所以湿热之邪是蛋白尿难消的主要病理因素。刘宝厚教授提出“湿热不除,蛋白难消”的学术思想,强调清除湿热的重要性。他认为感染和湿热的病机相同,主张肾脏病患者若有感染病灶存在,临床上就呈现不同程度的湿热证候的表现,治疗必须彻底清除湿热,才能收到好的疗效。刘宝厚教授清除湿热分三焦论治：上焦湿热采用经验方清热健肾汤加减治疗；中焦湿热,采用柴胡疏肝合三仁汤加减治疗,以宣通气机,燥湿利水；下焦湿热,采用经验方通淋健肾方加减治疗。通过典型的病例过早使用益气养阴之品,导致湿热留恋,蛋白难消,说明清除湿热的在急慢性肾脏病的诊治中的重要性,佐证了“湿热不除,蛋白难消”的学术思想。第四部分刘宝厚教授经验方清热健肾汤治疗紫癜性肾炎蛋白尿的临床观察目的：观察清热健肾汤治疗紫癜性肾炎蛋白尿的临床疗效。方法：将60例湿热血瘀型紫癜性肾炎患者随机分为治疗组30例和对照组30例。2组均采用西医常规疗法,治疗组加服清热健肾汤,治疗4周后,观察治疗前后24h尿蛋白总量变化,比较2组中医证候、尿蛋白临床疗效,评价蛋白尿转阴率。结果：治疗组在治疗后中医证候疗效、尿蛋白疗效及尿蛋白转阴率均明显优于对照组(P0.01),同时治疗组在治疗4周后,降低24h尿蛋白总量方面优于对照组(P0.05)。结论：清热健肾汤治疗紫癜性肾炎蛋白尿具有显著疗效,值得临床推广应用。
[Abstract]:Professor Liu Baohou is the national Ministry of human resources and social security, health and Family Planning Commission, the fifth batch of the academic experience of old TCM expert selection administration of traditional Chinese Medicine Inheritance instructor. In Chinese and Western medicine, teaching and research work for more than 60 years, 40 years of focus on kidney disease research, medicine and nephrology expert with home China's famous Chinese and Western medicine, the clinical experience for kidney disease rich, formed a lot of unique academic thoughts. The extensive collection of related data, systematic academic thought of Professor Liu Baohou, based on the progress of TCM diagnosis and treatment of traditional Chinese medicine treatment of nephrotic proteinuria and allergic purpura nephritis were reviewed. Professor Liu Baohou on the treatment of nephrotic proteinuria from the damp clinical experience were summarized. At the same time to heat the protein Nanxiao academic thought as the guidance of the experience The side heat Jianshen Decoction conducted a randomized controlled prospective clinical research, objective analysis of the clinical curative effect. In order to make the theory unique, academic thoughts and clinical experience inheritance and development, better service for patients. The research progress of Chinese medicine treatment of nephrotic proteinuria in the first part of the literature review from the cause of disease machine and TCM treatment based on syndrome differentiation, the TCM review on proteinuria disease pathogenesis is consistent, most of the doctors think the general pathogenesis in superficiality, deficiency in lung, spleen, kidney three dirty, standard real cold, wet, heat, blood stasis. The etiology, cause kidney failure sealed, foodstuff from urine outflow caused by deficiency and excess, and influence each other, leading to long lingering reciprocal causation and disease. In the treatment of nephrotic proteinuria, modern medicine is still very difficult, the majority of Chinese medicine experts on the treatment of both from the overall situation, How to reinforce the spleen and kidney, according to the different pathogenic factors selection of dispelling wind, heat, dampness, blood stasis and other treatment, can obtain good effect, but do not hurt is Quxie tonic, not stagnation. Allergic purpura nephritis (i.e. purpura nephritis) is the most serious complication of allergic purpura at present, it is a common clinical disease, its clinical manifestations can be divided into renal manifestations and renal manifestations. The most common clinical manifestations were hematuria, proteinuria, purpura nephritis with lingering illness, pathological features of recurrent, occurrence and damage degree of renal injury directly decide the prognosis of the disease in modern medicine. The etiology is not clear, is considered to be associated with infection and allergic reaction. From the analysis of the theory of traditional Chinese medicine, nothing more than evil ends, real evil to evil of wind, wet, heat, blood stasis and other real evil, is the deficiency in lung and spleen kidney three dirty Qi deficiency and yin deficiency more common vein damage, blood Don't follow through, overflow pulse is the basic pathogenesis, which is characterized in superficiality. Western medicine for this disease has no specific treatment, traditional Chinese medicine has obvious advantages in the treatment of the disease, especially in the control of purpura, proteinuria, hematuria and improve patient allergies and other aspects of the outstanding achievements. Specific treatment should be carried out disease staging diagnosis and treatment of the acute stage, first distinguish or chronic deferment. The acute stage with purpura originating as the main feature, the real standard, can be divided into hemopyretic bleeding type, damp heat in V type, blood stasis type; chronic purpura has been reduced or dissipated. With kidney damage, the false positive, positive imaginary evil love card, when both in the treatment of Fuzhengquxie, righting without leaving evil, Quxie without injury to the second part. Professor Liu Baohou's academic thought finishing national old TCM professor Liu Baohou In dozens of years of work, accumulated rich experience for kidney disease, and formed a lot of unique academic thinking. He encouraged innovation in the academic thought, I am particularly innovative. He study the formulation of "TCM syndrome differentiation of chronic glomerulonephritis" in Nanjing in 1985 Second National Academic Conference of Chinese medicine kidney disease on the adoption of national pilot program, and the income of the Ministry of health "Chinese medicine clinical research guiding principles", to a good effect on the diagnosis and treatment of chronic nephritis. The guide will lead in the domestic diagnosis applied to detect glomerular disease of blood stasis syndrome and blood rheology, evaluate the curative effect of Chinese Medicine on the diagnosis of kidney disease, blood stasis for a simple, easy and objective indicators, the relevant papers cited in China. Mr. Liu will physiological, pathological relationship between lung and kidney, generally known as the "lung and kidney related science Theory ", in order to more accurately reflect the relationship between TCM lung and kidney, and provide a theoretical basis for the prevention of lung disease how to elucidate the proposed" invigorating the kidney, lung and kidney related theory "in the prevention and treatment of chronic obstructive pulmonary disease have a certain significance. Advocate stage of treatment, he thinks the same disease in the pathological mechanism of different stages are different, so the treatment should be treated according to syndrome differentiation, the same disease, most can reflect the academic thought in his organic combination of Chinese and Western medicine treatment of nephrotic syndrome in stages in the process. Baohou Professor Liu proposed the" dual diagnosis of traditional Chinese medicine and Western medicine in clinic. Clinical medicine model with the combination of Chinese and Western medicine ", that the combination of traditional Chinese and Western medicine is the inevitable trend of medical development in our country, the key is to identify the combination of Chinese and Western medicine" combination point ", is whether it can improve the efficacy of diagnosis using traditional Chinese medicine and Western Medicine Dual diagnosis, according to disease, the organic combination of Western medicine in the treatment of general optimization combination, complement each other, improve the curative effect and reduce side effects. In his comprehensive analysis of kidney disease pathogenesis based on the combination of a large number of clinical practice, put forward the three essentials of TCM syndrome differentiation in the treatment of kidney disease, namely "Quxie Wu, from" Damp heat "; slow righting the protein '"; "blood stasis to kidney complex." Professor Liu Baohou proposed "the theory", that is not seen as tangible Sanjiao Fu, is not included in the six. It is divided into three regions according to the position of the internal organs of the body the gasification theory discussed the physiological function of the three regional viscera, and make it whole. Therefore, the triple energizer is actually just a theory, is the "gasification" theory. Professor Liu Baohou also advocated "syndrome differentiation to a combination of "The disease of syndrome differentiation and disease differentiation combined, put forward the" disease disease dialectics ", the dialectical method plays a leading role in the diagnosis and treatment of the disease process, provides an easy way for beginners of Chinese medicine. The third part Baohou from damp heat treatment on Professor Liu nephropathy clinical experience summarize the kidney plays an important role in TCM theory, it not only refers to the anatomy of the kidney, but also a physiological function is quite extensive, the growth and development of human reproduction, water metabolism, nervous, endocrine and metabolic organ has a direct or indirect relationship. Renal function is very important and special, a master of life the concept of the ancient medical home said." as the birth of the kidney "," root of life ". The reason for formation of damp heat in kidney disease is extremely complex, Professor Liu Baohou that the heat generated about the following two points: wet feeling Evil, wet body, two consistency, long Yu and heat, the formation of damp heat syndrome; and a large number of long-term use of hormone, time or true true Yin Yang deficiency, the body imbalance of yin and Yang, in water wet, the formation of damp heat syndrome. In kidney disease in the process of renal injury caused by damp heat, kidney pathological changes throughout the course, and often nephropathy end, leading factors in the process of the progress of the disease. The clinical findings of infection is the leading cause of kidney disease and recurrent disease, persistent disease, nephropathy patients easily repeated infection, characteristics of this and similar features of damp heat pathogen, longer duration and damp steaming lingering hard, patients with damp heat nephropathy is mostly related to secondary infection, especially infection and associated some hidden more closely. Proteinuria is substances can moisten the body but leaked from the urine caused by this deficiency is the main pathogenesis. Professor Liu Baohou believes that in clinical proteinuria Nanxiao, we should pay special attention to the feelings of the main pathological factors that damage the real evil, evil often influence Qi regulating, accumulation in vivo will increase the nutrient substance leakage, resulting in recurrent proteinuria in patients with damp heat evil lingering. Most lingering, most common in many real evil so, the damp heat evil is the main pathological proteinuria Nanxiao factors. Baohou Professor Liu proposed "heat is not removed, the protein Nanxiao academic thought, emphasizes the importance of clearing damp heat. He believed that the pathogenesis of infection and damp heat is the same as that of a kidney disease in patients with the infection, clinical appeared on damp heat syndrome when different levels of performance, we must eliminate the heat treatment, in order to receive good results. Professor Liu Baohou clear points of treatment: the damp heat damp heat by the side heat Jianshen Decoction in the treatment of middle Jiao; The combination of heat, ChaiHuShuGan Sanren decoction, in order to promote ventilation, dampness and water; damp heat in lower Jiao, the experience of Tonglin Decoction in the treatment of kidney health. The use of the product by supplementing qi and nourishing Yin typical cases of premature, resulting in hot and humid nostalgia, but illustrates the importance of clear protein, damp heat in acute and chronic kidney disease the diagnosis and treatment of the evidence of the heat is not removed, the protein Nanxiao academic thought. The fourth part Baohou Professor Liu experience heat Jianshen Decoction in the treatment of Henoch Schonlein purpura nephritis proteinuria clinical observation Objective: To observe the clinical curative effect of Qingre Jianshen Decoction in the treatment of purpura kidney inflammation proteinuria. Methods: 60 cases of damp heat and blood stasis Henoch Schonlein purpura nephritis were randomly divided into treatment group and control group 30 cases of 30 cases of.2 group were treated with conventional therapy, the treatment group added Qingre Jianshen decoction, 4 weeks after treatment, the changes of 24h content of urine protein before and after treatment were observed and compared between the 2 groups of traditional Chinese Medicine The syndrome, the clinical curative effect of urinary protein, urine protein negative rate evaluation. Results: in the treatment group after treatment of TCM syndrome curative effect, curative effect of urine protein and urine protein negative rate was significantly better than the control group (P0.01), the treatment group in 4 weeks after treatment at the same time, reduce 24h urine total protein than the control group (P0.05). Conclusion: Qingre Jianshen Decoction in the treatment of Henoch Schonlein purpura nephritis proteinuria has remarkable curative effect, worthy of clinical application.

【学位授予单位】：中国中医科学院
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R249;R277.5

【参考文献】