曹恩泽辨治慢性肾衰学术思想总结与研究

发布时间：2018-06-16 02:10

本文选题：老中医药专家 + 学术经验　；参考：《南京中医药大学》2016年博士论文

【摘要】：目的：系统总结国家级名老中医曹恩泽教授辨治慢性肾脏病的临证经验、辨证思路、诊治规律和学术思想；并以导师根据其临证经验创立的治疗慢性肾衰基本法——“清降补益通络法”为指导,总结研究曹恩泽教授诊治慢性肾衰的辨证思想,诊疗方法和用药规律；并开展“清降补益通络法”辨治慢性肾衰竭的临床及实验研究,丰富慢性肾脏病的中医药治疗学内容。本课题通过总结和继承名老中医临床经验和学术思想并结合科学方法予以研究,达到继承和发扬名老中医学术精粹,促进祖国医学发展的目的。方法：通过跟随导师侍诊学习,记录导师诊疗各种慢性肾脏病的临证医案并加以整理研究、体会总结,进行慢性肾衰临床医案整理研究,总结曹师辨治慢性肾衰病的临证经验、诊治辨证思路、用药规律和学术思想。采集导师治疗慢性肾衰竭临床病案220例次,依据导师诊治辨证分型、组方用药,结合数据挖掘技术和统计分析,观察研究慢性肾衰患者初诊证型分布规律、中药使用频次、药—证关系和各证型用药规律,总结出以“清降补益通络法”为指导治疗慢性肾衰的基本方药和各证型常用药物。开展“清降补益通络法”基本方辨治慢性肾衰竭的临床研究,选取120例符合慢性肾衰竭诊断标准非透析患者,分为治疗组60例与对照组60例。治疗组服用基本方,对照组服用尿毒清颗粒治疗,疗程12周。观察并记录治疗前后两组患者血清Scr、BUN、Cys C变化以及治疗前后临床疗效和中医证候积分值变化情况。同时选取55只SD大鼠,分为正常组、模型组、基本方组与缬沙坦组,制备UUO大鼠模型,观察各组大鼠血清Scr、BUN和肾脏病理变化,并检测UUO大鼠肾脏组织p-转化生长因子(TGF-β)、肝细胞生长因子(HGF)、α-平滑肌肌动蛋白(α-SMA)和纤维连接蛋白(FN)免疫组化半定量评分情况。结果：曹恩泽教授认为慢性肾衰病程冗长,病因病机繁杂,临证之时要紧抓脾肾亏虚为本及浊毒瘀血蕴结为标的病机,尤其是浊毒弥漫三焦为其病机之关键,可依据三焦所属脏腑的病理变化、临床表现及传变关系,探求其证治规律,并在临证中创立了从三焦辨治慢性肾衰的证治规律。邪犯上焦分为肺肾气虚、风邪侵袭和浊毒内蕴、上犯心肺两型。肺肾气虚、风邪侵袭型予玉屏风散加减以补肺益肾治疗：浊毒内蕴、上犯心肺型又当分湿浊上犯心包和湿浊化热内陷心包二证,湿浊上犯心包证予菖蒲郁金汤合温脾汤加减,湿浊化热、内陷心包证当予牛黄承气汤加减。邪犯中焦包括脾肾气虚、湿浊内蕴型,脾肾阳虚、寒湿困阻型和脾肾亏虚、湿热蕴结型,为大多数慢性肾衰患者病变进程之所在,临床多见,为临证辨治重点。脾肾气虚、湿浊内蕴型以曹师自拟清补降浊方加减以健脾益肾、降浊化瘀为治；脾肾阳虚,寒湿困阻型治以健脾燥湿,和胃降浊,以曹师自拟清降汤Ⅰ号加减；脾肾亏虚,湿热蕴结型以曹师自拟清降汤Ⅱ号方清热化湿、降浊和胃为治。邪犯下焦分为肝肾阴虚、风阳上扰和阴阳两虚、浊毒弥漫两型。肝肾阴虚、风阳上扰型以镇肝熄风汤加减滋阴潜阳,镇肝熄风；阴阳两虚、浊毒弥漫型方用参附汤及黑锡丹加减温阳益气固脱为治。曹师诊治慢性肾衰虽以三焦辨证为纲,分型辨治。但同时曹师强调在临证中需注重“审证求机,知常达变,复合立法”原则,抓住慢性肾衰的基本病机,创立“清降补益通络法”为辨治慢性肾衰的基本法则。该法据慢性肾衰“虚、湿浊、瘀”的病机立论,予立“清降、清补结合活血通络”法辨治,曹师自拟清降汤Ⅰ号和清降汤Ⅱ号方均是该法的应用体现。同时曹师认为瘀血是慢性肾病重要的病理因素,故提出“化瘀通络”治法当贯穿慢性肾衰治疗始终,又根据病之标本虚实常采用扶正祛瘀和活血祛邪两类治法。曹师认为肾脏病虽病本在肾,但脾胃与肾密切相关,“百病皆由脾胃衰而生也”,故肾病辨治应注重培补脾胃,提出“慢性肾衰可从脾辨治”观点。曹师指出虫类药物多性味辛、咸,辛能散、能行,可行气活血； “咸先入肾”,可引诸药直通肾络,达化瘀通络,起护肾之功。慢性肾衰为肾病之终末期,非一药所能建功,故临证习以全蝎、地龙、僵蚕和蝉蜕配对使用。曹师认为慢性肾衰病机以虚为本,补法是其常用治法,但此时脾。肾俱虚,已失其运化固摄之功,过补则易伤阴动血,阻滞气机,导致肾衰加重,故需“用药轻灵”,应以平补为宜,切忌温补,勿使中焦壅滞。应用数据挖掘技术对曹师诊治慢性肾衰医案研究分析得出以“清降补益通络”为具体治法的核心处方,核心方药包括生大黄、煅龙骨、煅牡蛎、槐米、土茯苓、地龙、生黄芪、全蝎、僵蚕和苍术,共计10味中药。应用该基本方辨治慢性肾衰竭结果显示在中医证侯和临床疗效方面,治疗组优于对照组(P0.05),治疗组临床总有效率、中医证候总有效率分别为90%、88.33%,显著高于对照组的75%、73.33%(P0.05)。两组治疗后SCr、BUN和CysC均较治疗前明显降低(P0.01),GFR水平显著升高(P0.01),但基本方治疗组与同期对照组比较,Scr、BUN和CysC均明显降低(P0.05,或P0.01),GFR水平显著升高(P0.01)。治疗期间未出现药物不良反应。为探求其作用机理,开展了“清降补益通络法”基本方干预UUO大鼠肾间质纤维化的实验研究。研究结果显示该方可改善大鼠生存质量,降低UUO大鼠血BUN、Scr和肾小管间质损伤指数(P0.01,P0.05),减轻大鼠肾脏病理损害；治疗后基本方组UUO大鼠肾脏组织TGF-β1、α-SMA和FN着色半定量评分较模型组和缬沙坦组降低,而HGF评分较模型组和缬沙坦组降升高,差异有显著性(P0.01,P0.05)。说明清降补益通络基本方可以通过降低肾脏组织FN水平,下调α-SMA表达；同时抑制强效致纤维化因子TGF-β1的表达,促进抗纤维化因子HGF的生成达到抗肾脏纤维化的效果。结论：曹恩泽教授辨治慢性肾衰将中医经典理论与临证经验有机结合,依据慢性肾衰脾肾亏虚为本,浊毒瘀血蕴结弥漫三焦为标的基本病机提出了从三焦辨治慢性肾衰的证治规律,在临证中创立“清降补益通络法”为辨治慢性肾衰的基本法则。经数据挖掘研究总结出“清降补益通络法”辨治慢性。肾衰的基本方药,通过对该基本方治疗慢性肾衰竭的临床和实验研究,结果显示疗效均显著,证明“清降补益通络法”及代表方是辨治非透析阶段慢性肾衰竭患者的有效治疗方法。同时曹师提出眠陧性肾衰可从脾辨治”, “活血化瘀通络法当贯穿慢性肾衰治疗始终”和“慢性肾衰需用药轻灵”等辨治理论,丰富了慢性肾脏病的中医药治疗学内容。
[Abstract]:Objective: to systematically summarize the clinical experience, syndrome differentiation, diagnosis and treatment of Professor Cao Enze, a national famous traditional Chinese medicine, and to summarize and study Professor Cao Enze's diagnosis and treatment of chronic renal failure with the guidance of the basic method of treating chronic renal failure based on the experience of his tutor in the treatment of chronic renal failure. The clinical and Experimental Research on the treatment of chronic renal failure by "clearing up tonifying the benefits and dredging collaterals" and enriching the content of TCM therapeutics of chronic kidney disease are carried out. The subject is studied by summarizing and inheriting the clinical experience and academic thought of the old traditional Chinese medicine and combining scientific methods to achieve inheritance and development. The purpose of promoting the development of Chinese medicine is to promote the development of Chinese medicine. Methods: by following the study of the tutor's service, we record the tutor's diagnosis and treatment of various chronic kidney diseases and collate the medical case, experience the summary, study the clinical medical records of chronic renal failure and summarize the experience of the diagnosis and treatment of chronic renal failure. 220 cases of clinical case of chronic renal failure were collected by tutor in the treatment of chronic renal failure. According to the diagnosis and treatment of syndrome differentiation by tutor, prescription medication, combined with data mining and statistical analysis, the distribution law of the initial diagnosis of chronic renal failure was observed and studied. The frequency of use, the relationship between medicine and syndrome and the laws of various types of drug use were summarized. The basic prescription and commonly used medicine for the treatment of chronic renal failure is a basic prescription for the treatment of chronic renal failure. A clinical study on the basic prescription of "clearing up and dredging the collaterals" in the treatment of chronic renal failure is carried out. 120 cases of non dialysis patients with chronic renal failure are selected and divided into 60 cases in the treatment group and 60 cases in the control group. The treatment group takes the basic prescription and the control group. The group was treated with Niu Du Qing granule for 12 weeks. The changes of serum Scr, BUN, Cys C and the changes of clinical curative effect and TCM syndrome score before and after treatment were observed and recorded before and after treatment. At the same time, 55 SD rats were selected to be divided into normal group, model group, basic group and valsartan group, to prepare UUO rat model and observe the blood of rats in each group. Clear Scr, BUN and renal pathological changes, and detect the semi quantitative score of p- transforming growth factor (TGF- beta), hepatocyte growth factor (HGF), alpha smooth muscle actin (alpha -SMA) and fibronectin (FN) in renal tissue of UUO rats. Results: Cao Enze taught that chronic renal failure has long course, complicated etiology and pathogenesis. The key to the pathogenesis of the spleen and kidney deficiency is the deficiency of the spleen and kidney, especially the turbid poison and blood stasis, especially the turbid and toxic diffuse tri coke. It can be based on the pathological changes of the Zang Fu organs of the three focal points, the clinical manifestation and the transmission relationship, and explore the rule of the syndrome and treatment. Deficiency, wind evil invasion and turbidity and poison inside, two types of heart and lung, lung kidney qi deficiency, wind evil invasion to Yuping wind dispersion to supplement lung and kidney treatment: turbidity and poison inside, the upper offense of heart and lung type pericardium pericardium and wet turbid invagination pericardial pericardium, pericardium tululu soup combined with warm spleen soup, wet turbid heat, entrapped pericardium syndrome When the decoction of Niuhuang Chengqi is added and subtracted, the middle of the evil offense includes spleen and kidney qi deficiency, wet cloudy implication, spleen and kidney yang deficiency, cold dampness hindrance and spleen kidney deficiency, and spleen kidney deficiency, and damp heat accumulation, which is the most common clinical diagnosis and treatment for most patients with chronic renal failure. Kidney, turbidity and stasis of blood stasis for treatment; spleen and kidney yang deficiency, cold dampness and hindrance treatment by Invigorating the spleen and drying wet, and stomach turbidity, with the Cao teacher to make the decoction of clearing down the soup. Kidney yin deficiency, wind yang to disturb the liver Qi Decoction to reduce nourishing Yin latent Yang, town liver extinguishing wind, yin and yang two deficiency, cloudy and toxic diffuse type of decoction of Shenfu and Xisan adding and reducing temperature Yang Qi fixation for treatment. According to the principle of "legislation", grasp the basic pathogenesis of chronic renal failure and establish the basic law of "clearing up tonifying the benefit and dredging collaterals" as the basic law for the diagnosis and treatment of chronic renal failure. According to the pathogenesis of chronic renal failure "deficiency, wet turbid, and stasis", the method is established to establish "clearing down, clearing up combined with activating blood circulation and collaterals". At the same time, Cao teachers think that blood stasis is an important pathological factor of chronic kidney disease. Therefore, the treatment method of "removing blood stasis and dredging collaterals" is always used throughout the treatment of chronic renal failure. According to the deficiency and reality of the disease, two kinds of treatment methods are used to relieve the blood stasis and activate blood and dispel evil, and the kidney disease is in the kidney, but the spleen and stomach are closely related to the kidney. The disease of the stomach is born, so the diagnosis and treatment of kidney disease should pay attention to the cultivation of the spleen and stomach, put forward "chronic renal failure can be treated by the spleen". I think that the chronic renal failure pathogenesis is based on the deficiency of the chronic kidney failure machine and the supplement method is the common treatment, but at this time the spleen. The spleen. The kidney is weak, it has lost its movement and fixation, the overfill is easy to hurt the Yin blood, block the Qi machine and cause the kidney failure to aggravate, so it should be "light with the medicine". Using data mining technology, the core prescription of "clearing up and replenishing the collaterals" is the core prescription of the treatment of chronic renal failure. The core prescriptions include 10 flavors, including rhubarb, calcined keel, calcined oysters, Sophora japonica, Radix Astragalus, Radix Astragali, scorpion, silkworm and Atractylodes. The results of chronic renal failure showed that the treatment group was better than the control group (P0.05). The total effective rate of the treatment group was 90% and 88.33%, which was significantly higher than that of the control group, 75% and 73.33% (P0.05). The two groups were significantly lower than before the treatment (P0.01), BUN and CysC after treatment (P0.01), and the GFR level increased significantly. High (P0.01), but the basic treatment group compared with the same control group, Scr, BUN and CysC significantly decreased (P0.05, or P0.01), GFR level increased significantly (P0.01). No adverse drug reaction during the treatment. To explore the mechanism of its action, the basic prescription of "clearing up tonifying the dredging collaterals" in the experimental study of renal interstitial fibrosis in UUO rats was carried out. The results showed that this prescription could improve the quality of life of rats, reduce the blood BUN, Scr and renal tubulointerstitial damage index (P0.01, P0.05) of UUO rats and reduce the pathological damage of kidney in rats. After treatment, the renal tissue TGF- beta 1 in the basic group of UUO rats, the semi quantitative score of alpha -SMA and FN coloring was lower than the model group and valsartan group, while the HGF score was compared with the model group and valsartan. The difference is significant (P0.01, P0.05). It shows that the basic prescription of clearing up tonifying tonifying collaterals can reduce the FN level of renal tissue and reduce the expression of alpha -SMA; meanwhile, it inhibits the expression of TGF- beta 1, and promotes the formation of anti fibrosis factor HGF to achieve the effect of anti renal fibrosis. Conclusion: Professor Cao Enze has a slow differentiation and treatment. The basic principle of treating chronic renal failure with three focal points is put forward by the basic pathogenesis of chronic renal failure based on the deficiency of spleen and kidney of chronic renal failure and the basic pathogenesis of treating chronic renal failure with triple coke. According to the clinical and experimental study of the basic prescription for chronic renal failure in the treatment of chronic renal failure, the results show that the curative effect of the basic prescription in the treatment of chronic renal failure is significant. It is proved that the "clearing up tonifying the dredging collaterals" and the representative are effective methods for the treatment of patients with chronic renal failure in non dialysis stage. The theory of "activating blood and removing blood stasis and dredging collaterals through the treatment of chronic renal failure" and "chronic renal failure should be treated with light spirit" has enriched the content of Chinese medicine therapy for chronic kidney disease.
【学位授予单位】：南京中医药大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R249;R277.5

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