本文選題：老中醫(yī)藥專家 + 學(xué)術(shù)經(jīng)驗(yàn)��； 參考：《南京中醫(yī)藥大學(xué)》2016年博士論文

【摘要】：目的：系統(tǒng)總結(jié)國家級名老中醫(yī)曹恩澤教授辨治慢性腎臟病的臨證經(jīng)驗(yàn)、辨證思路、診治規(guī)律和學(xué)術(shù)思想；并以導(dǎo)師根據(jù)其臨證經(jīng)驗(yàn)創(chuàng)立的治療慢性腎衰基本法——“清降補(bǔ)益通絡(luò)法”為指導(dǎo),總結(jié)研究曹恩澤教授診治慢性腎衰的辨證思想,診療方法和用藥規(guī)律；并開展“清降補(bǔ)益通絡(luò)法”辨治慢性腎衰竭的臨床及實(shí)驗(yàn)研究,豐富慢性腎臟病的中醫(yī)藥治療學(xué)內(nèi)容。本課題通過總結(jié)和繼承名老中醫(yī)臨床經(jīng)驗(yàn)和學(xué)術(shù)思想并結(jié)合科學(xué)方法予以研究,達(dá)到繼承和發(fā)揚(yáng)名老中醫(yī)學(xué)術(shù)精粹,促進(jìn)祖國醫(yī)學(xué)發(fā)展的目的。方法：通過跟隨導(dǎo)師侍診學(xué)習(xí),記錄導(dǎo)師診療各種慢性腎臟病的臨證醫(yī)案并加以整理研究、體會總結(jié),進(jìn)行慢性腎衰臨床醫(yī)案整理研究,總結(jié)曹師辨治慢性腎衰病的臨證經(jīng)驗(yàn)、診治辨證思路、用藥規(guī)律和學(xué)術(shù)思想。采集導(dǎo)師治療慢性腎衰竭臨床病案220例次,依據(jù)導(dǎo)師診治辨證分型、組方用藥,結(jié)合數(shù)據(jù)挖掘技術(shù)和統(tǒng)計分析,觀察研究慢性腎衰患者初診證型分布規(guī)律、中藥使用頻次、藥—證關(guān)系和各證型用藥規(guī)律,總結(jié)出以“清降補(bǔ)益通絡(luò)法”為指導(dǎo)治療慢性腎衰的基本方藥和各證型常用藥物。開展“清降補(bǔ)益通絡(luò)法”基本方辨治慢性腎衰竭的臨床研究,選取120例符合慢性腎衰竭診斷標(biāo)準(zhǔn)非透析患者,分為治療組60例與對照組60例。治療組服用基本方,對照組服用尿毒清顆粒治療,療程12周。觀察并記錄治療前后兩組患者血清Scr、BUN、Cys C變化以及治療前后臨床療效和中醫(yī)證候積分值變化情況。同時選取55只SD大鼠,分為正常組、模型組、基本方組與纈沙坦組,制備UUO大鼠模型,觀察各組大鼠血清Scr、BUN和腎臟病理變化,并檢測UUO大鼠腎臟組織p-轉(zhuǎn)化生長因子(TGF-β)、肝細(xì)胞生長因子(HGF)、α-平滑肌肌動蛋白(α-SMA)和纖維連接蛋白(FN)免疫組化半定量評分情況。結(jié)果：曹恩澤教授認(rèn)為慢性腎衰病程冗長,病因病機(jī)繁雜,臨證之時要緊抓脾腎虧虛為本及濁毒瘀血蘊(yùn)結(jié)為標(biāo)的病機(jī),尤其是濁毒彌漫三焦為其病機(jī)之關(guān)鍵,可依據(jù)三焦所屬臟腑的病理變化、臨床表現(xiàn)及傳變關(guān)系,探求其證治規(guī)律,并在臨證中創(chuàng)立了從三焦辨治慢性腎衰的證治規(guī)律。邪犯上焦分為肺腎氣虛、風(fēng)邪侵襲和濁毒內(nèi)蘊(yùn)、上犯心肺兩型。肺腎氣虛、風(fēng)邪侵襲型予玉屏風(fēng)散加減以補(bǔ)肺益腎治療：濁毒內(nèi)蘊(yùn)、上犯心肺型又當(dāng)分濕濁上犯心包和濕濁化熱內(nèi)陷心包二證,濕濁上犯心包證予菖蒲郁金湯合溫脾湯加減,濕濁化熱、內(nèi)陷心包證當(dāng)予牛黃承氣湯加減。邪犯中焦包括脾腎氣虛、濕濁內(nèi)蘊(yùn)型,脾腎陽虛、寒濕困阻型和脾腎虧虛、濕熱蘊(yùn)結(jié)型,為大多數(shù)慢性腎衰患者病變進(jìn)程之所在,臨床多見,為臨證辨治重點(diǎn)。脾腎氣虛、濕濁內(nèi)蘊(yùn)型以曹師自擬清補(bǔ)降濁方加減以健脾益腎、降濁化瘀為治；脾腎陽虛,寒濕困阻型治以健脾燥濕,和胃降濁,以曹師自擬清降湯Ⅰ號加減；脾腎虧虛,濕熱蘊(yùn)結(jié)型以曹師自擬清降湯Ⅱ號方清熱化濕、降濁和胃為治。邪犯下焦分為肝腎陰虛、風(fēng)陽上擾和陰陽兩虛、濁毒彌漫兩型。肝腎陰虛、風(fēng)陽上擾型以鎮(zhèn)肝熄風(fēng)湯加減滋陰潛陽,鎮(zhèn)肝熄風(fēng)；陰陽兩虛、濁毒彌漫型方用參附湯及黑錫丹加減溫陽益氣固脫為治。曹師診治慢性腎衰雖以三焦辨證為綱,分型辨治。但同時曹師強(qiáng)調(diào)在臨證中需注重“審證求機(jī),知常達(dá)變,復(fù)合立法”原則,抓住慢性腎衰的基本病機(jī),創(chuàng)立“清降補(bǔ)益通絡(luò)法”為辨治慢性腎衰的基本法則。該法據(jù)慢性腎衰“虛、濕濁、瘀”的病機(jī)立論,予立“清降、清補(bǔ)結(jié)合活血通絡(luò)”法辨治,曹師自擬清降湯Ⅰ號和清降湯Ⅱ號方均是該法的應(yīng)用體現(xiàn)。同時曹師認(rèn)為瘀血是慢性腎病重要的病理因素,故提出“化瘀通絡(luò)”治法當(dāng)貫穿慢性腎衰治療始終,又根據(jù)病之標(biāo)本虛實(shí)常采用扶正祛瘀和活血祛邪兩類治法。曹師認(rèn)為腎臟病雖病本在腎,但脾胃與腎密切相關(guān),“百病皆由脾胃衰而生也”,故腎病辨治應(yīng)注重培補(bǔ)脾胃,提出“慢性腎衰可從脾辨治”觀點(diǎn)。曹師指出蟲類藥物多性味辛、咸,辛能散、能行,可行氣活血； “咸先入腎”,可引諸藥直通腎絡(luò),達(dá)化瘀通絡(luò),起護(hù)腎之功。慢性腎衰為腎病之終末期,非一藥所能建功,故臨證習(xí)以全蝎、地龍、僵蠶和蟬蛻配對使用。曹師認(rèn)為慢性腎衰病機(jī)以虛為本,補(bǔ)法是其常用治法,但此時脾。腎俱虛,已失其運(yùn)化固攝之功,過補(bǔ)則易傷陰動血,阻滯氣機(jī),導(dǎo)致腎衰加重,故需“用藥輕靈”,應(yīng)以平補(bǔ)為宜,切忌溫補(bǔ),勿使中焦壅滯。應(yīng)用數(shù)據(jù)挖掘技術(shù)對曹師診治慢性腎衰醫(yī)案研究分析得出以“清降補(bǔ)益通絡(luò)”為具體治法的核心處方,核心方藥包括生大黃、煅龍骨、煅牡蠣、槐米、土茯苓、地龍、生黃芪、全蝎、僵蠶和蒼術(shù),共計10味中藥。應(yīng)用該基本方辨治慢性腎衰竭結(jié)果顯示在中醫(yī)證侯和臨床療效方面,治療組優(yōu)于對照組(P0.05),治療組臨床總有效率、中醫(yī)證候總有效率分別為90%、88.33%,顯著高于對照組的75%、73.33%(P0.05)。兩組治療后SCr、BUN和CysC均較治療前明顯降低(P0.01),GFR水平顯著升高(P0.01),但基本方治療組與同期對照組比較,Scr、BUN和CysC均明顯降低(P0.05,或P0.01),GFR水平顯著升高(P0.01)。治療期間未出現(xiàn)藥物不良反應(yīng)。為探求其作用機(jī)理,開展了“清降補(bǔ)益通絡(luò)法”基本方干預(yù)UUO大鼠腎間質(zhì)纖維化的實(shí)驗(yàn)研究。研究結(jié)果顯示該方可改善大鼠生存質(zhì)量,降低UUO大鼠血BUN、Scr和腎小管間質(zhì)損傷指數(shù)(P0.01,P0.05),減輕大鼠腎臟病理損害；治療后基本方組UUO大鼠腎臟組織TGF-β1、α-SMA和FN著色半定量評分較模型組和纈沙坦組降低,而HGF評分較模型組和纈沙坦組降升高,差異有顯著性(P0.01,P0.05)。說明清降補(bǔ)益通絡(luò)基本方可以通過降低腎臟組織FN水平,下調(diào)α-SMA表達(dá)；同時抑制強(qiáng)效致纖維化因子TGF-β1的表達(dá),促進(jìn)抗纖維化因子HGF的生成達(dá)到抗腎臟纖維化的效果。結(jié)論：曹恩澤教授辨治慢性腎衰將中醫(yī)經(jīng)典理論與臨證經(jīng)驗(yàn)有機(jī)結(jié)合,依據(jù)慢性腎衰脾腎虧虛為本,濁毒瘀血蘊(yùn)結(jié)彌漫三焦為標(biāo)的基本病機(jī)提出了從三焦辨治慢性腎衰的證治規(guī)律,在臨證中創(chuàng)立“清降補(bǔ)益通絡(luò)法”為辨治慢性腎衰的基本法則。經(jīng)數(shù)據(jù)挖掘研究總結(jié)出“清降補(bǔ)益通絡(luò)法”辨治慢性。腎衰的基本方藥,通過對該基本方治療慢性腎衰竭的臨床和實(shí)驗(yàn)研究,結(jié)果顯示療效均顯著,證明“清降補(bǔ)益通絡(luò)法”及代表方是辨治非透析階段慢性腎衰竭患者的有效治療方法。同時曹師提出眠隉性腎衰可從脾辨治”, “活血化瘀通絡(luò)法當(dāng)貫穿慢性腎衰治療始終”和“慢性腎衰需用藥輕靈”等辨治理論,豐富了慢性腎臟病的中醫(yī)藥治療學(xué)內(nèi)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.
【學(xué)位授予單位】：南京中醫(yī)藥大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R249;R277.5

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6 許嚇k，

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