【作者】 王志强；

【导师】 谢桂权；

【作者基本信息】 广州中医药大学 ， 中医内科学， 2007， 博士

【摘要】 目的：通过调查收集符合纳入标准病例的一般情况、症状、部分体征、舌脉象以及部分实验室检查指标，采用传统中医辨证与现代聚类分析方法，深入系统研究珠三角地区成人原发性肾病综合征的症候、证型特点，为岭南地区成人肾病综合征的中医辨证分型标准研究及指导临床实践，提供客观、科学的依据。方法：主要采用回顾性调查研究方法。严格按照入选标准选择珠江三角洲地区的各大中医院(包括广州中医药大学第一附属医院、第二附属医院、深圳市中医院、佛山中医院、中山市中医院)2004年1月至2006年12月的住院病人，及广州中医药大学第一附属医院本期间的部分门诊病人，确诊为原发性肾病综合征的成年患者，收集包括人口学一般情况、自主症状、舌脉象、体征、实验室检查等资料，观察、分析患者的症候分布，分别采用传统中医辨证方法和聚类分析方法分析患者的证型分布，并用方差分析、秩和检验分析实验室指标与中医证型的相关性。结果：本研究入选病例共331例，部分病例根据水肿期、非水肿期分别收集两次资料，共收集资料480例次。其中水肿期336例次，非水肿期144例次。所收集病历的病程长短不一，从最短几天到最长20余年不等，而水肿期与非水肿期患者的病程有显著性差别(P＜0.01)，年龄、性别无差别。成人原发性肾病综合征患者的自主症状中出现较多的症状有下肢肿(68.3％)、乏力(51.7％)、纳差(47.1％)、面肿(42.7％)、尿少(40.8％)、疲倦(35.4％)、腰酸(32.5％)等，水肿期出现最多的症状为纳差(44.3％)，其次有乏力(43.4％)、小便少(41.1％)、口干(33.0％)、疲倦(32.7％)、腹胀(32.1％)、便溏(24.4％)、腰酸(23.2％)、尿黄(18.7％)、面色萎黄(17.0％)等。非水肿期出现最多的症状为乏力(74.3％)，其次为腰部酸痛(54.2％)、纳差(53.5％)、疲倦(41.7％)、小便少(40.3％)、肢冷(31.3％)、腿软(27.8％)、口干(23.6％)、失眠(22.9％)等。从采集的自主症状来看，水肿期及非水肿期虚证症状均明显多于实证症状。水肿期虚证中，从气血阴阳虚分析，气虚(48.5％)最多，其次为阳虚(9.5％)、阴虚(8.0％)，最少的为血虚(3.3％)。从五脏虚分析，脾虚最多，占水肿期总病例数的53.3％，其次为肾虚(47.0％)、心虚(14.3％)，最少为肝虚(4.8％)。从复合虚证分析，脾肾气虚最多，占所有病例的15.2％；其次为脾肾阳虚(9.2％)，气阴两虚(7.4％)、阴阳两虚(2.7％)、肺肾气虚(1.2％)；肝肾阴虚(0.9％)最少。水肿期实证中除水湿外以湿热最多，占所有病例数的34.2％；其次为血瘀(15.8％)、外感(15.2％)、湿浊(3.9％)；气滞(0.8％)最少。临床上，水肿期大多数病例表现为虚实错杂证(83.3％)，其中单独表现为实证的证型有湿热、湿浊、外感等三种。虚实夹杂证中较多见的有脾肾气虚兼水湿、脾肾阳虚兼水湿、脾肾气虚兼湿热、脾肾气虚兼血瘀等。用聚类分析方法将水肿期样本分成7个证型，实证有外感、湿热、湿浊，其中湿热组样本例数最多；虚实夹杂证中脾肾气虚兼水湿组的样本例数远远多于脾肾阳虚兼水湿组；其次为脾肾气虚兼湿热、脾肾气虚兼血瘀，与传统辨证方法的结果基本一致。非水肿期虚证中，以气血阴阳虚证分析，阴虚(50.7％)最多，其次为气虚(50.0％)、阳虚(20.8％)，最少的为血虚(4.9％)。以五脏虚证分析，非水肿期肾虚(43.8％)最多，其次为脾虚(37.5％)、心虚(12.5％)，最少为肝虚(5.6％)。复合虚证中气阴两虚(29.2％)最多，其次为脾肾气虚(25.0％)、脾肾阳虚(6.3％)；肺肾气虚(0.7％)最少。非水肿期实证中以湿热(34.7％)最多，其次为血瘀(31.9％)、外感(11.8％)、湿浊(11.8％)；气滞(2.1％)最少。非水肿期患者在临床上多表现为虚实错杂的情况(93.7％)。非水肿期外感、湿浊证均与虚证夹杂；湿热及血瘀证各有不同比例的样本为单独实证者。聚类分析结果：非水肿期最多见的实证有湿热、血瘀；最常见的虚证为脾肾气虚和气阴两虚；虚实夹杂证中以气阴两虚兼湿浊、肺虚外感多见。结论：珠江三角洲地区成人原发性肾病综合征调查研究结果初步显示：1．原发性肾病综合征的症候分布特点：从症状分布来看，成人原发性肾病综合征无论水肿期还是非水肿期均以虚证症状多见。2．原发性肾病综合征证型分布特点：水肿期最常见的实证有水湿、湿热、湿浊、外感，其中水湿、湿热最多；单种虚证中以气虚、脾虚、肾虚最多，复合虚证中以脾肾气虚最多。虚实夹杂证最常见的有脾肾气虚兼水湿、脾肾阳虚兼水湿、脾肾气虚兼湿热、脾肾气虚兼血瘀等，其中脾肾气虚兼水湿比脾肾阳虚兼水湿多见。非水肿期最常见的证型包括实证有湿热、血瘀，其中湿热最多见；单种虚证中以阴虚、气虚、肾虚、脾虚最多，复合虚证常见的有气阴两虚和脾肾气虚等，其中气阴两虚最多见；虚实夹杂证中以气阴两虚兼湿浊、肺虚外感多见。3．水肿期与非水肿期的证型临床表现特征为虚实夹杂证多见，且虚实并见的类型比较复杂，往往是多个证型夹杂出现在同一病例中。4．实验室检查与证型相关性研究表明：水肿期患者脾肾阳虚型血浆白蛋白偏低，外感证患者血浆球蛋白偏低。更多还原

【Abstract】 Objective:The purpose of this research is using Cluster and other statistical analysis method to evaluate the syndrome and laboratory examinations of PNS patients which were investigated from hospitals in the Pearl Triangle and then to find out the principle of TCM diagnosis on these PNS patients, and find out the relationship between TCM diagnosis and laboratory examinations.ethods:It’ saretrospect research. Through strictly selective criterion, we chose the PNS in-patients of the main TCM hospitals in the Pearl Triangle, such as The First Hospital of Guangzhou TCM University, the Shenzhen Hospital of TCM, The Foshan Hospital of TCM, The Zhongshan Hospital of TCM, then collected their demography data, individual medical record, independent syndrome, and laboratory examination results etc., Finally, put these data into SPSS11.5 software to evaluate their contributions, and then draw out the primary TCM diagnosis on PNS.Result:This research comprises 331 patients, some patients data were collected twice according to different period in diseases-edema period and non edema period. Thus we collected 480 cases finally, including 336 edema cases and 144 nonedema cases. The courses of disease of these cases are different widely from days to over 20 years. There is static significant different of the course from edema and non edema cases and no significant different of ages and sexes from edema and non edema cases.The most commonly seen independent symptoms of PNS are both lower extremities edema, lassitude, poor appetite, face edema, oliguria, languor, lumber soreness and so on. The most commonly seen independent symptoms of edema period cases are poor appetite, at 44.3%, lassitude, at 43.4%, short urine, at 41.1%, dry mouth, at 33.0% tired, at 32.7%, abdominal distension, at 32.1%, diarrhea, at 24.4%, waist soreness, at 23.2%, yellow urine, at 18.7% and flavocomptexion, at 17.0% and so on. The most commonly seen independent symptoms of non edema period cases are lassitude, at 74.3%, waist soreness, at 54.2%, poor appetite, at 53.7%, tired, at 41.7%, short urine, at 40.3% cold extremities, at 31.3%, insomnia, at 22.9% and so on. Observing these symptoms, we find out that deficiency symptoms are more often than the demonstration symptoms.In edema cases, basing on the diagnose criterion of syndrome of deficiency of Yin-Yang and Qi-Blood, the most commonly syndrome is the Qi deficiency, at 48.5%, and the next one is Yang deficiency, at 9.5%, then is the Yin deficiency, at 8.0%. The Blood deficiency is the least one, at 3.3%. Basing on the diagnose criterion of syndrome of deficiency of five viscera, syndrome of spleen deficiency is the most commonly one which rate is 53.3%, following by syndrome of kidney deficiency, at 47.0%, the heart deficiency, at 14.3%, the liver deficiency syndrome is the least one, which rate is 4.8%. Basing on the criterion of deficiency of-syndrome of complicated deficiency, it is the syndrome of Qi deficiency of both kidney and spleen the most commonly seen syndrome (15.2%), following by the Qi-Yin deficiency (7.4%), the Yin-Yang deficiency (2.7%), the Qi deficiency of both lung and kidney (1.2%), and the Yin deficiency of both sliver and kidney (0.9%). In demonstrated syndromes,the damp-heat syndrome (34.2%) is the most commonly one except damp syndrome, following by the blood stagnation syndrome (15.8%), the catching cold syndrome (15.2%), the damp-dirty syndrome (3.9%), and the Qi stagnation syndrome (0.8%) is the least one in them. In clinic, the TCM syndromes of PNS in edema stage are most complicated with deficiency syndromes and demonstration, which rate is 83.3%. Only the damp-heat syndrome, the damp-dirty syndrome and the catching cold syndrome are displaying as demonstration. The most commonly complicated syndrome of the edema cases are the damp and the Qi deficiency of both spleen and kidney, the damp and the Yang deficiency of both spleen and kidney, the damp-heat and the Qi deficiency of both spleen and kidney and the blood stagnation and the Qi deficiency of both spleen and kidney. After cluster analysis, the edema cases are divided into 7 clusters, the syndromes of these clusters are the same as upper. In non edema cases, basing on the diagnose criterion of syndrome of deficiency of Yin-Yang and Qi-Blood, the most commonly syndrome is the Yin deficiency, at 50.7%, and the next one is Qi deficiency, at 50%, then is the Yang deficiency, at 20.8%. The Blood deficiency is the least one, at 4.9%. Basing on the diagnose criterion of syndrome of deficiency of five viscera, the syndrome of kidney deficiency is the most commonly one which rate is 43.8%, following by syndrome of spleen deficiency, at 37.5%, the heart deficiency, at 12.5%, the liver deficiency syndrome is the least one, which rate is 5.6%. Basing on the criterion of deficiency of syndrome of complicated deficiency, it is the syndrome of Qi-Yin deficiency the most commonly seen syndrome (29.2%), following by the Qi deficiency of both spleen and kidney (25.0%), the Yang deficiency of both spleen and kidney (6.3%), the Qideficiency of both lung and kidney (1.2%) is the least one. In demonstrated syndromes, the damp-heat syndrome (34.7%) is the most commonly syndrome, following by the blood stagnation syndrome (31.9%), the catching cold syndrome (11.8%), the damp-dirty syndrome (11.8%), and the Qi stagnation syndrome (2.1%) is the least one in them. In clinic, like edema cases the TCM syndromes of PNS of non edema cases are most complicated with deficiency syndromes and demonstration also, which rate is 93.7%. Only the damp-heat syndrome, the blood stagnation syndrome is displaying as demonstration, and the catching cold syndrome and the damp-dirty syndrome are complicated with deficiency syndromes.The most commonly deficiency syndrome of the non edema cases are the Qi deficiency of both spleen and kidney and the Qi-Yin deficiency syndrome. The most commonly complicated syndrome of the non edema cases are the damp-dirty and the Qi-Yin deficiency syndrome, the catching cold and the deficiency of lung. After cluster analysis, the non edema cases are divided into 7 clusters, the syndromes of these clusters are the same as upper.Conclusion:The results of the research of symptom and syndrome of PNS in the Pearl Triangle show that:1. Form the analysis of the occurrence of symptom in PNS cases, we found out that the deficiency symptoms are more than the demonstrated symptoms in both edema cases and non edema cases2. In edema stage, the most commonly demonstrated syndromes of PNS are the damp-heat syndrome, the damp-dirty syndrome and the catching cold syndrome. The most commonly complicated syndrome of the edema cases are the damp and the Qi deficiency of both spleen and kidney, the damp and the Yang deficiency of both spleen and kidney, the damp-heat and the Qi deficiency of both spleen and kidney and the blood stagnation and the Qi deficiency of both spleen and kidney. In non edema stage, the most commonly demonstrated syndromes of PNS are the damp-heat syndrome, the damp-dirty syndrome and the catching cold syndrome. The most Commonly deficiency syndrome of the non edema cases are the Yang deficiency of spleen and kidney, the Qi deficiency of both spleen and kidney and the Qi-Yin deficiency syndrome. The most commonly complicated syndrome of the non edema cases are the damp-dirty and the Qi-Yin deficiency syndrome and the catching cold and the deficiency of lung.3. The character of the syndrome of both edema and non edema stage cases is that deficiency and demonstrated syndromes are complicated sophisticated.4. The research of the relationship of laboratory examinations and TCM syndromes show that in edema stage, the quantity of blood albumin of the patients who is suffered the Yang deficiency of spleen and kidney is fewer than the patients who has other syndromes. And the quantity of blood globulin of the patients who has the catching cold syndrome is fewer than that who has other syndrome.更多还原