本文關(guān)鍵詞：劉寶厚教授學(xué)術(shù)思想及從濕熱論治腎病蛋白尿臨證經(jīng)驗整理研究　出處：《中國中醫(yī)科學(xué)院》2016年博士論文　論文類型：學(xué)位論文

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【摘要】：劉寶厚教授是國家人力資源與社會保障部、衛(wèi)生與計劃生育委員會、中醫(yī)藥管理局遴選的第五批全國老中醫(yī)藥專家學(xué)術(shù)經(jīng)驗繼承指導(dǎo)老師。從事中西醫(yī)醫(yī)療、教學(xué)和科研工作60余年,專注研究腎臟病40余年,是我國著名的中西醫(yī)結(jié)合醫(yī)學(xué)家和腎臟病學(xué)專家,在臨床上積累了豐富的腎臟病治療經(jīng)驗,形成了諸多獨特的學(xué)術(shù)思想。本文廣泛收集相關(guān)資料,系統(tǒng)整理劉寶厚教授學(xué)術(shù)思想,在綜述了中醫(yī)藥治療腎病蛋白尿及過敏性紫癜性腎炎的中醫(yī)診治研究進展基礎(chǔ)上,對劉寶厚教授從濕熱論治腎病蛋白尿臨證經(jīng)驗進行了全面的總結(jié),同時對以“濕熱不除,蛋白難消”學(xué)術(shù)思想為指導(dǎo)的經(jīng)驗方清熱健腎湯進行了前瞻性的隨機對照臨床研究,客觀分析其臨床療效。力求使獨具特色的理論見解、學(xué)術(shù)思想及臨證經(jīng)驗得以傳承和發(fā)揚,更好的為患者服務(wù)。第一部分文獻綜述從病因病機及中醫(yī)辨證論治等方面進行綜述中醫(yī)藥治療腎病蛋白尿的研究進展,綜述示目前中醫(yī)對蛋白尿的病位病機認(rèn)識漸趨一致,多數(shù)醫(yī)家認(rèn)為其總的病機為本虛標(biāo)實,本虛以肺、脾、腎三臟為主,標(biāo)實以寒、濕、熱、瘀等病因為主,導(dǎo)致腎失封藏、水谷精微從尿液外流所致,且本虛與標(biāo)實相互影響、互為因果,導(dǎo)致病久纏綿難愈。在腎病蛋白尿的治療方面,現(xiàn)代醫(yī)學(xué)仍感很棘手,多數(shù)中醫(yī)專家從整體論治兼顧虛實,多以補益脾腎為主,針對不同外邪選用祛風(fēng)、清熱、除濕、化瘀等治則,可取得良好療效,但都做到“祛邪勿傷正,補虛勿壅滯”。過敏性紫癜性腎炎(即紫癜性腎炎)是過敏性紫癜最嚴(yán)重的并發(fā)癥,是目前臨床常見疾病,其臨床表現(xiàn)多樣,可分為腎外表現(xiàn)和腎臟表現(xiàn)。最常見的臨床表現(xiàn)是血尿、蛋白尿,紫癜性腎炎具有病情纏綿、反復(fù)發(fā)作的病理特點,腎損傷的發(fā)生及其損害程度直接決定該病的預(yù)后。現(xiàn)代醫(yī)學(xué)對于其病因尚未明確,目前認(rèn)為可能與感染和變態(tài)反應(yīng)有關(guān)。從中醫(yī)理論分析,不外乎正邪兩端,邪實以風(fēng)邪、水濕、熱毒、瘀血等實邪為主,正虛則以肺脾腎三臟氣虛及陰虛多見,脈絡(luò)受損,血不循經(jīng),溢出脈外是其基本病機,其特點是本虛標(biāo)實。西醫(yī)對本病尚無特效治療措施,中醫(yī)藥在該病的治療方面有明顯的優(yōu)勢,特別是在控制紫癜、蛋白尿、血尿以及改善患者過敏體質(zhì)等方面卓有成效。具體治療應(yīng)進行辨病分期辨證治療,首先分清急性活動期還是慢性遷延期。急性活動期以紫癜始發(fā)為主要特征,以標(biāo)實為主,大致可分為血熱妄行型、濕熱內(nèi)伏型、瘀血阻絡(luò)型；慢性遷延期紫癜多已減少或消退,伴有腎臟損害,此時以正虛為主,為正虛邪戀之證,治療當(dāng)扶正祛邪并重,總以扶正不留邪,祛邪而不傷正為要。第二部分名老中醫(yī)劉寶厚教授學(xué)術(shù)思想整理國家級名老中醫(yī)劉寶厚教授在數(shù)十年的工作中,積累了豐富的腎臟病治療經(jīng)驗,并形成了諸多獨特的學(xué)術(shù)思想。他在學(xué)術(shù)思想上鼓勵創(chuàng)新,本人特別勇于創(chuàng)新。他研究制訂的“慢性腎小球腎炎中醫(yī)辨證分型方案”,在1985年南京第二次全國中醫(yī)腎臟病學(xué)術(shù)會議上采納為全國試行方案,并由衛(wèi)生部收入《中藥新藥臨床研究指導(dǎo)原則》,對指導(dǎo)慢性腎炎的診治起到了良好的效應(yīng)。率先在國內(nèi)將血液流變學(xué)檢測運用于腎小球疾病血瘀證的診斷、中醫(yī)辨證及療效評估上,為腎臟病血瘀證的診斷建立了一種簡便、易行的客觀指標(biāo),其有關(guān)論文在國內(nèi)被廣泛引用。劉老師將肺腎之間的生理、病理聯(lián)系,概括地稱之為“肺腎相關(guān)理論”,以期能更準(zhǔn)確地反映中醫(yī)肺腎之間的內(nèi)在聯(lián)系,對闡明補腎法何以能防治肺系疾病提供理論依據(jù),提出的“肺腎相關(guān)理論”在防治慢性阻塞性肺病上確有一定的指導(dǎo)意義。倡導(dǎo)分階段論治,他認(rèn)為同一疾病在不同階段其病理機制也不同,因此在治療時應(yīng)按辨證分型進行治療,此即同病異治,在他采取中西藥有機結(jié)合分階段治療腎病綜合征過程中最能體現(xiàn)這一學(xué)術(shù)思想。劉寶厚教授在臨床中提出“中西醫(yī)雙重診斷,中西藥有機結(jié)合”的臨床醫(yī)學(xué)模式,認(rèn)為中西醫(yī)結(jié)合是我國醫(yī)學(xué)發(fā)展的必然趨勢,中西醫(yī)結(jié)合的關(guān)鍵在于找準(zhǔn)“結(jié)合點”,標(biāo)準(zhǔn)是能否提高療效,在診斷上采用中西醫(yī)雙重診斷,參照辨病辨證情況,在治療上將中西藥有機結(jié)合,優(yōu)化組合,取長補短,提高療效同時可減輕副作用。他在全面分析腎臟病病因病機基礎(chǔ)上,結(jié)合大量的臨床實踐,提出腎臟病中醫(yī)辨證論治的三大要領(lǐng),即“祛邪務(wù)盡,扶正從緩”；“濕熱不除,蛋白難消”；“瘀血不去,腎氣難復(fù)”。劉寶厚教授提出“三焦學(xué)說”,認(rèn)為三焦既不能看作有形之腑,也不能列入六腑之中。它是古人根據(jù)臟腑所處的人體部位劃分了三個區(qū)域,用氣化學(xué)說論述了三個區(qū)域內(nèi)臟腑的生理功能,并使其整體化。所以,三焦實際上只是一個學(xué)說,是講“氣化作用”的學(xué)說。劉寶厚教授還提倡“辨證之要,位性合參”,把病位辨證與病性辨證有機結(jié)合起來,提出“病位病性辨證法”,這種辨證方法在診治疾病過程中起到提綱挈領(lǐng)的作用,為初學(xué)中醫(yī)者提供了簡便易行的方法。第三部分劉寶厚教授從濕熱論治腎病蛋白尿臨證經(jīng)驗總結(jié)腎在中醫(yī)臟腑學(xué)說中占有重要的地位,它不僅指解剖學(xué)上的腎臟,而且是一個生理功能相當(dāng)廣泛,與人體生殖、生長發(fā)育、水液代謝、神經(jīng)、內(nèi)分泌代謝等均有直接或間接關(guān)系的重要臟器。腎的作用重大而特殊,有主宰生命之概念。故歷代醫(yī)學(xué)家稱“腎為先天之本”,“生命之根”。腎臟病中濕熱形成的原因極其復(fù)雜,劉寶厚教授認(rèn)為濕熱的產(chǎn)生大概有以下兩點：感受濕邪,體內(nèi)生濕、二者相合,日久郁而化熱,形成濕熱之證；以及長期服用大量激素,日久抑真陽損真陰,使機體陰陽平衡失調(diào),內(nèi)生水濕,形成濕熱之證。在腎臟病過程中,濕熱傷腎,引起腎病病理改變,且往往貫穿腎病病程的終始,在病情進展的過程中起主導(dǎo)因素。臨床發(fā)現(xiàn)感染是引起腎病加重和反復(fù)發(fā)作的主要原因,腎病病情遷延不愈,腎病患者易反復(fù)感染,這一點與濕熱致病的特點相似,即病程較長及濕熱蘊蒸纏綿難解的特點,濕熱型腎病患者大多與繼發(fā)性感染有關(guān),尤其與一些隱性的感染病灶關(guān)聯(lián)更為密切。蛋白尿是精微物質(zhì)不能濡養(yǎng)機體反而從尿液中漏出所致,本虛標(biāo)實為主要病機。劉寶厚教授認(rèn)為在臨床上蛋白尿難消,應(yīng)特別重視感受實邪損傷的主要病理因素,實邪往往影響氣機調(diào)暢,蘊結(jié)于體內(nèi)會加重精微物質(zhì)的漏出,致使蛋白尿患者反復(fù)發(fā)作、纏綿難愈。濕熱之邪最纏綿難愈,在眾多實邪之中最多見,所以濕熱之邪是蛋白尿難消的主要病理因素。劉寶厚教授提出“濕熱不除,蛋白難消”的學(xué)術(shù)思想,強調(diào)清除濕熱的重要性。他認(rèn)為感染和濕熱的病機相同,主張腎臟病患者若有感染病灶存在,臨床上就呈現(xiàn)不同程度的濕熱證候的表現(xiàn),治療必須徹底清除濕熱,才能收到好的療效。劉寶厚教授清除濕熱分三焦論治：上焦?jié)駸岵捎媒?jīng)驗方清熱健腎湯加減治療；中焦?jié)駸?采用柴胡疏肝合三仁湯加減治療,以宣通氣機,燥濕利水；下焦?jié)駸?采用經(jīng)驗方通淋健腎方加減治療。通過典型的病例過早使用益氣養(yǎng)陰之品,導(dǎo)致濕熱留戀,蛋白難消,說明清除濕熱的在急慢性腎臟病的診治中的重要性,佐證了“濕熱不除,蛋白難消”的學(xué)術(shù)思想。第四部分劉寶厚教授經(jīng)驗方清熱健腎湯治療紫癜性腎炎蛋白尿的臨床觀察目的：觀察清熱健腎湯治療紫癜性腎炎蛋白尿的臨床療效。方法：將60例濕熱血瘀型紫癜性腎炎患者隨機分為治療組30例和對照組30例。2組均采用西醫(yī)常規(guī)療法,治療組加服清熱健腎湯,治療4周后,觀察治療前后24h尿蛋白總量變化,比較2組中醫(yī)證候、尿蛋白臨床療效,評價蛋白尿轉(zhuǎn)陰率。結(jié)果：治療組在治療后中醫(yī)證候療效、尿蛋白療效及尿蛋白轉(zhuǎn)陰率均明顯優(yōu)于對照組(P0.01),同時治療組在治療4周后,降低24h尿蛋白總量方面優(yōu)于對照組(P0.05)。結(jié)論：清熱健腎湯治療紫癜性腎炎蛋白尿具有顯著療效,值得臨床推廣應(yīng)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.

【學(xué)位授予單位】：中國中醫(yī)科學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R249;R277.5

【參考文獻】

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1 蔣佳梅;羅旭;張香卉;鄭獎;詹華奎;;葉傳蕙教授治療慢性腎病蛋白尿經(jīng)驗拾珍[J];四川中醫(yī);2015年01期

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