慢性肾功能衰竭的中医辨治经验

Experience in Differential Diagnosis of Syndromes and Treatment of Chronic Renal Faihue with Traditional Chinese Medicine

慢性肾衰的中医病名以关格较为恰当,鉴于其中医病机为正虚邪实,而且在病程中有虚实主次之异,因而笔者在1984年提出了关格病分为虚损期、关格期两期的新概念。虚损期的临床表现以一派虚损症状为主;关格期具有典型的下关上格的特征。 慢性肾衰的病因与素体脾肾虚弱,加之过劳与外邪等诱因均密切相关。正虚邪实,“因虚致实”是其病机特点。正虚之中以气阴两虚最为多见,邪实有外邪、水停、湿浊、瘀血、风动、蕴痰、肠胃燥结等诸种。 治疗慢性肾衰首先应权衡标本缓急,缓则治本,根据辨证的结果,采用相应的益气、补血、养阴、助阳之法以扶助正气。对于最多见的气阴两虚证,宜气阴双补,常用方为参芪地黄汤,临床运用时应权衡气阴两虚的偏重情况,选用好诸参系列药。急则治标,务使邪有出路。表邪微汗以解,水停渗湿于下,肠胃燥结则通腑泻浊等。 关于大黄的应用,笔者注重选择制剂、用量、煎法、配合扶正药四个方面。肠胃燥结甚者用生大黄;轻者或年老或正虚较甚者均选制大黄。用量及煎法因人而宜。对于便溏甚至腹泻者不宜选用大黄。 对于关格期患者治疗注重调理脾胃。温胃降浊法宜于脾胃气虚兼挟寒湿者,常用方为香砂六君子汤。清胃降浊法宜于湿热中阻者。常用方为黄连温胆汤、苏叶黄连汤。

Chronic renal failure(CRF)is similar to Guange(关格)disease of Traditional Chinese Medicine (TCM). Its pathogenesis in TCM is deficiency of healthy energy and sthenia of evil, and its clincal manifestations in the course are different in both the nature of asthenia and sthenia, and the severity. Therefore, I first proposed that Guange disease should be divided into the asthenic stage and the Guange stage in 1984. The main manifestation is deficiency syndrome in the asthenic stage, and typical characteristics of the upper rejection (vomiting) and the lower closure(oliguria)in the Guange stage.The etiology of CRF is closely related to constitutional deficiency of both spleen and kidney, and to predisposing factors, such as overexertion and exogenous evils and so on. The nature of the pathogenesis is deficiency of healthy energy and sthenia of evil, and deficiency of healthy energy inducing sthenia of evil. The deficiency of both Qi and Yin is the most frequently seen in deficiency of healthy energy, while sthenia of evil has exogenous evils, water retention, turbidwetness, blood stasis, wind - evil stirring, plegm accumulation and dryness constipation in gastrointestinal tract, and so on. The treatment of CRF should be determined in accordance with primary or secondary syndrome, and chronic or aoute syndrome. The one principle is relieving the primary syndrome in a chronic case, tonifying Qi, nourishing blood, replenishing Yin and reinforcing Yang may be selected in order to strengthen healthy energy on the basis of the results of differentiating syndrome. As for the most commonly seen the deficiency of both Qi and Yin, both Qi and Ying are replenished at the same time and the commonly used prescription is Shen Qi Di Huang Tang decootion(黄芪地黄汤) . Meanwhile, Shens(参类药物) should be selected properly according to Predominant Qi or Ying deficiency. The other principle is relieving the secondary syndrome in an acute case, letting the evils out. The superficial evil be treated with slight diaphoresis, edema with diuresis and constipation with purgation and eliminating turbid evil, etc.As regards the application of Radix et Rhizoma Rhei, I emphasize selecting of its kind of preparations, dosage, decocting method and compatible application of drugs with strengthening healthy energy effect. Raw Radix et Rhizoma Rhei is used in patients with severe dryness retention in the gastrointestinal tract, prepared Radoix et Rhizoma Rhei in mild case, elderly patients and patients with remarkable deficiency of healthy energy, and not used in patients with loose stool or even diarrhea. The dosage and decocting method should be individualized.The regulation of the functions of both spleen and stomach should be emphasized in the patients with Guange stage. Warming stomach and eliminating turbid evil are used in the patients with Qi deficiency of both spleen and stomach accompanying cold - wetness, and the commonly used prescription is Xiang Sha Liu Jun Zhi Tang decoction( 香砂六君子汤). Clearing stomach and eliminating turbid evil are used in the patients with wetness - heat retention in the middle warmer, and the commonly used prescriptions are Huang Lian Wen Dan Tang decoction (黄连温胆汤) and Su ye Huang Lian Tang decoction (苏叶黄连汤).