【作者】 刘淑娟；

【导师】 黄春林；

【作者基本信息】 广州中医药大学 ， 中医内科学， 2005， 博士

【摘要】 一、临床研究—尿毒症心肌病的临床回顾性分析 1.目的 回顾性分析尿毒症心肌病中医证候学特征,研究中医证候分布规律以指导进一步的临床及实验研究。 2.方法 回顾性调查以往2年来广东省中医院肾内科住院病历,按照尿毒症心肌病的诊断标准,纳入具有尿毒症心肌病表现者,共筛选出住院病历53份,按照原始住院病历记录如实填写尿毒症心肌病临床病历资料观察表。其中尿毒症早期14例(26.4%),尿毒症末期39例(73.6%);男性31例(58.5%),女性患者22例(41.5%);年龄最小24岁,最大87岁,平均49.7±12.5;病程最短0.25年,最长30年,平均8.3±3.7年。原发疾病为慢性肾小球肾炎37例,肾病综合征7例,梗阻性肾病4例,狼疮性肾炎3例,多囊肾2例。通过观察中医正虚证、邪实证的分布规律,研究尿毒症心肌病中医证候学特征。 3.结果 3.1 尿毒症心肌病患者正虚证以脾肾气虚证最为多见,尿毒症心肌病中医证型分布以脾肾气虚和脾肾阳虚为主,共41例(77.4%)。53例患者中脾肾气虚证占34例(64.2%),其次为脾肾阳虚证和气阴两虚证(共13例,占24.4%)。在尿毒症早期,脾肾气虚证占50%,尿毒症末期,脾肾气虚证则居主要地位,占69.2%。 3.2 尿毒症心肌病患者常以2种以上的邪实证兼夹的表现同时出现在疾病的过程中,邪实证以湿浊瘀阻证最为多见(36例,占66.7%)。尿毒症早期以湿浊瘀阻证(42.9%)、水湿内蕴证(28.6%)多见,其次为湿热瘀阻证(21.4%);尿毒症末期则76.9%的患者均表现为湿浊瘀阻证。 3.3 通过对尿毒症心肌病患者不同分期的超声心动图分析发现,反映心脏结构的指标:左心房内径(LAD)在两组患者之间无明显差异(P>0.05),左心室舒张末内径(LVD)、室间隔厚度(IVS)、左室后壁厚度(LVPW),以及反映心脏功能的指标:射血分数(EF),两组患者组间比较均有显著性差异(P<0.05)。说明随着尿毒症的进展,对心肌的损害程度随之加重,心肌肥厚进展,心室腔发生扩大,心脏功能呈下降趋势。 4.结论 4.1 尿毒症心肌病均表现为虚实夹杂证,其中虚证以脾肾气虚及脾肾阳虚最为多见;邪实证则多见两种邪实证兼夹,邪实以湿浊瘀阻证最为多见。 4.2 尿毒症早期,即有室间隔及左室后壁的增厚,左房扩大,部分患者出现左室内径的增大,此期以心脏舒张功能减退多见;随着尿毒症的进一步进展,心肌进一步受累,更多还原

【Abstract】 PART Ⅰ Retrospective Study on Uremic Cardiomyopathy 1.Objective:To summarize the clinic feature in differential syndrome of TCM of uremic cardiomyopathy patients. 2.Method:Using a retrospective study design to investigate the chronic renal failure (CRF) patients with uremic cardiomyopathy.53 cases rage 24-87 years old with uremic cardiomyopathy of at least one half year’s duration were enrolled,included 37 cases of chronic glomerulonephritis,7 cases of nephrotic syndrome,4 cases of obstructive nephropathy, 3 cases of lupus nephritis,and 2 cases of polycystic kidney disease. 3. Result:3.1 Of the uremic cardiomyopathy,spleen and kidney Qi deficiency (34 cases,64.2%),spleen and kidney Yang dificiency (7 cases,13.2%)are the main.3.2 In the course of uremic cardiomyopathy,usually more than 2 cases of excess syndromes are mingled. The frequency of different types of excess syndrome from high to low is linger and stagnation of damp turbility and static blood(36 cases,66.7%),water damp(7 cases, 13.2%).3.3 Through the analysis of UCG,two stages of uremic cardiomyopathy have obvious difference.As a result of cardiac hypertrophy,ventricular delated, the function of heart decreased.4.Conclusions:4.1 Uremic cardiomyopathy subjects manifested as deficiency syndrome mingled withexcess syndrom. In the deficiency syndromes,spleen and kidney Qi deficiency, spleen andkidney Yang dificiency are the main.In the excess syndromes, linger and stagnation ofdamp turbility and static blood are the main.4.2 In the early stage of uremic cardiomyopathy,myeocardial reconstruction has play a rule.The myocardial damage is strongly related with CRF.PATE Ⅱ Experimental Sudy on Uremic Cardiomyopathy Rats Treated withDunaiqing Granules1.Objective:To clarify the efficiency and passible mechanisms of Dunaiqing Granules in the remic cardiomyopathy rats. 2.Methods:Fifty male SD rats were made uremic cardiomyopathy.45 successful model rats with CRF were divided into five groups randomly.Model Group(administered with NS 2ml/d),High Dose Group(administerde with Dunaiqing 4.5g/kg.d),Low Dose Group (administered with Dunaiqing 2.25g/kg.d),Captopril Group(administered with 6.25mg/ kg.d).9 age-matched male SD rats were sreved as controls(administered with NS 2ml/d) 8 years later, contents of serum creatinine(Scr),BUN were determined.The myocardial ultrastructure of lefe ventricular (LV) were observed through transmission electric microscope,collagen volume fraction were calculated with automatic imaging analyzing system after VG staining.The apoptosis of myocardial cells was mensured by TUNEL methods. 3.Results:3.1 The condition of Model Group deteriorate.The level of BUN,Scr was significantly increased than Control Group.The rats’ condition of Dunaiqing’s two dosage groups were inproved obviously than controls,especially the hign dose group.The conditions of aptopril Group is lightly improved.3.2 Under the microscope,the model group’s myocardial cells nucleus contract,and the original fiber of muscle arranges mess,etc.Both Dunaiqing and Captopril groups have obviously improved the pathological changes showed in ultrastructure:the myocardial cell nucleus slightly tidy,the muscle syrup inside track is more.muscle cell nucleus near to normal.3.3 The level of HWI and LVMI, and the lecel of CVF and PVCA in Captopril Group and Dunaiqing Groups were significantly lower than models.3.4 Apoptosis was found in Control Group by chance.In the Model Group apoptosis of myocardial cells were detected.The apoptosis index(AI) of Captopril Group and both of Dunaiqing Groups have a obvious decline.4.conclusion:4.1 The uremic cardiomyopathy rats appeared pathological changes in ultrastructure.更多还原