慢性肾衰竭患者住院期间受寒后突发冷凝集素病,表现肾功能进展,溶血性贫血,经过中西医结合治疗,患者转危为安.冷凝集素病在寒冷环境下可引起血液中红细胞凝集,基于《素问·调经论篇》曰:"血气者喜温而恶寒,寒则泣不能流,温则消而去之."中医认为该病的基本病机为寒凝血瘀,治疗需重视温阳活血治法,具体包括温阳散寒、温阳益气、活血化瘀、温阳利水,常用方如四逆汤、四逆加人参汤、茯苓四逆汤、当归四逆汤、真武汤等,并随病情发展,观其脉证,随证治之,如兼有脾虚者,要健脾和胃;兼有气血亏虚者,要益气养血;兼有湿热者,要清化湿热.

中性粒细胞由骨髓造血干细胞分化而来,是人体免疫系统的重要组成部分.当成人外周血中性粒细胞(NE)计数低于0.5×109/L或完全缺乏时,称为粒细胞缺乏症(agranulocytosis).粒细胞缺乏症患者免疫力低下,发生感染时表现不明显,可能仅以发热为临床征象,目前治疗主要包括尽早抗感染、对症使用升白药物等,但由于患者感染部位不明确或难以发现,病原菌培养阳性率低,难以给予精准的抗感染治疗,而多在经验性应用广谱抗生素的基础上,配合中医治疗可以在短时间内改善病情、减少并发症,改善预后.

目的 探讨慢性肾脏病(chronic kidney disease,CKD)3～5期非透析患者肾性贫血与铁缺乏的相关性及影响因素.方法 回顾性分析2020年6月至2021年12月就诊于首都医科大学附属北京中医医院的143例CKD3～5期非透析患者的临床资料.根据患者是否存在肾性贫血分为贫血组(126例)与非贫血组(17例);根据患者是否存在铁缺乏分为铁缺乏组(55例)与非铁缺乏组(88例).记录CKD不同分期患者的肾性贫血与铁缺乏情况.分析肾性贫血与铁缺乏的相关性以及CKD3～5期患者肾性贫血和铁缺乏的独立影响因素.结果 本研究中,肾性贫血的总发病率为88.11％(126/143),铁缺乏的总发病率为38.46％(55/143).CKD3期、4期、5期患者肾性贫血的发病率分别为74.47％(35/47)、88.89％(40/45)、100％(51/51),铁缺乏的发病率分别为38.30％(18/47)、35.56％(16/45)、41.18％(21/51).Spearman相关性分析结果显示,血红蛋白与转铁蛋白饱和度呈正相关(r=0.193,P<0.05),与铁蛋白无明显相关性(r=-0.012,P=0.883);肾性贫血与铁缺乏无明显相关性(r=-0.065,P=0.441).多因素logistic回归分析结果显示,二氧化碳结合力是CKD3～5期患者肾性贫血的独立影响因素(P<0.05);平均动脉压、心率是CKD3～5期患者铁缺乏的独立影响因素(P<0.05).结论 CKD3～5期患者普遍存在肾性贫血与铁缺乏,二者之间无明显相关性,且受二氧化碳结合力、平均动脉压、心率等因素影响.

目的 探讨桃红四物汤合五苓散加减联合氢氯噻嗪治疗慢性肾衰竭(CRF)血瘀水湿证的临床疗效.方法 选择首都医科大学附属北京中医医院及北京市平谷区中医医院肾病科门诊2018年4月—2020年5月收治的CRF血瘀水湿证患者60例,按照随机数字表法分为观察组和对照组各30例.对照组给予常规治疗+口服氢氯噻嗪片,观察组在对照组基础上联合桃红四物汤合五苓散加减治疗,疗程2个月.所有受试者治疗前后进行中医证候积分、36项健康调查简表(SF-36)及急性生理和慢性健康状况评分Ⅱ(APACHE Ⅱ)评分,并检测肾功能指标血清肌酐(Cr)、尿素氮(BUN)水平及24 h尿蛋白定量(24h-UTP),以及血清炎症指标,包括白介素-6(IL-6)、肿瘤坏死因子-α(TNF-α)、C反应蛋白(CRP)浓度,统计不良反应发生情况.结果 观察组总有效率为90.0％,对照组为60.0％,2组比较差异有统计学意义(P＜0.01).与治疗前比较,治疗后2组中医证候积分均降低(P＜0.01),观察组低于对照组(P＜0.01).与治疗前比较,治疗后2组血清Cr、BUN、IL-6、TNF-α、CRP及24h-UTP均降低(P＜0.01),观察组指标低于对照组(P＜0.01).与治疗前比较,治疗后2组SF-36评分均升高(P＜0.05),APACHE Ⅱ评分均降低(P＜0.01);与对照组比较,治疗后观察组SF-36评分升高,APACHEⅡ评分降低(P＜0.01).2组不良反应均较少且轻微.结论 桃红四物汤合五苓散加减联合氢氯噻嗪治疗CRF血瘀水湿证能显著下调患者血清相关炎症因子的表达水平,改善肾功能,安全且有效.

Gitelman 综合征(Gitelman syndrome,GS)是一种遗传性罕见病,属于常染色体隐性遗传的失盐性肾小管疾病.1966年,美国医生Gitelman等首先报道了3例患者而得名,其临床表现为低钾血症、低镁血症、低尿钙症及代谢性碱中毒.Gitelman综合征的病因:编码位于肾脏远曲肾小管的噻嗪类利尿剂敏感的钠氯共同转运体(NCCT)蛋白的基因——溶质转运家族12成员3(SLC12A3),发生功能缺失突变,导致NCCT的结构和/或功能异常,继而导致远曲肾小管对钠氯重吸收障碍,导致血容量降低、肾素-血管紧张素-醛固酮系统(RAAS)激活、低钾血症以及代谢性碱中毒等一系列的病生理改变及临床表现.[1]基因筛查是目前确诊GS的金标准[2],笔者介绍新疆和田地区人民医院肾内科收治的1例维吾尔族GS患者.

缓解性血清阴性对称性滑膜炎伴凹陷性水肿(remitting seronegative symmetrical synovitis with pitting edema,RS3PE)综合征是一种特殊类型的以关节炎为主要表现的风湿性疾病,属于中医学"痹证"范畴,多由素体禀赋不足,正气亏虚,感受风寒湿邪,入里化热,痹阻四肢关节而成.本案初诊以局部辨证代替了整体辨证,误诊为湿热痹阻关节,以热为盛,方用四妙勇安汤加减治疗无效.二诊吸取教训,局部辨证与整体辨证相结合,考虑外感风寒湿邪,入里化热,痹阻手足关节,气血不通,不通则痛,治疗以外散风寒湿邪,内清里热,方选桂枝芍药知母汤加减,取得良效.因此,RS3PE综合征辨证需重视局部辨证和整体辨证相结合,同时治疗过程中需顾护胃气.

临床思维是将医学基础知识转化为临床实践的重要途径,在诊疗疾病的过程中,如何将中西医临床思维融会贯通,发挥其各自优势,是现代中医临床学习和教学的难点之一.文章以慢性肾脏病为例,探讨"病-证-症"三位一体辨治思维模式在临床教学中的应用,以辨病、辨证、辨症为纲,层层推进,在辨病中锻炼学生综合运用多种思维方法的能力,重视对疾病基本病机的探索,全面而立体地认识疾病;在辨证和辨症中既要立足传统,又要吸收现代研究成果,从多角度分层次进行分析,从而提高学习效果,提升临床能力.

中医住院医师规范化培训是医教协同深化中医学人才培养改革的关键环节,是加强中医临床人才队伍建设的有效途径.基于线上线下混合式教学模式利用信息技术促进学习方式的创新,是传统教学模式的丰富和完善,实现信息技术与高等教育深度融合.通过线上"国家级名老中医微信小课堂""百度云资源共享""腾讯会议APP学习交流小课堂""问卷星中医经典网络测评",结合线下"中医经典小课堂""肾病科疑难病例讨论""科研组会学习"混合式教学实践,可培养学生自主学习和探索式学习的能力,促进了教学质量提高,为培养高质量的中医临床人才提供可能.

中医住院医师规范化培训是医教协同深化中医学人才培养改革的关键环节.目前中医住院医师规范化培训已经取得了较大成效,但总体上尚处于起步阶段,在实施过程中尚存在推进进度不一、基地分布不均、培训水平差异较大、培训时间安排不合理等问题.随着规培基地招生规模的不断扩大,学员生源的多元化,出现了学员自主学习能力差、缺乏团队合作意识、中医临床思维弱化等新的问题.在信息社会背景下,基于智能手机的移动学习为医学教育的发展带来新的契机,可以激发规培学员的学习兴趣和热情,有望成为住院医师规范化培训的重要补充,提高学员的综合素质,值得不断的思考与探索.

干燥综合征病机通常被认为是阴虚,但按其治疗有时无效.以一气周流理论解读干燥综合征病机为三焦气机阻滞,为上焦失于肃降而生火、中焦轴运迟废而成饮、下焦化源匮而成虚,如此气机升降失常,津液失于敷布,或痰饮阻滞,或郁而化热,伤津致燥,用一气周流理论指导干燥综合征的中医诊治以期打开临床新思路.

Objective To observe the curative effect of Jianpi Bushen Degui Decoction on malnutrition in chronic kidney disease (CKD) of stage 3-4.Methods 90 CKD patients of stage 3-4 with malnutrition were randomly divided into the control group and treatment group according to random number table,each with 45 cases.Both of two groups were given basic treatment.The control group was added with compound alpha keto acid tablets,4 tablets each time,3 times a day;the treatment group was added with Jianpi Bushen Digui Decoction for 2 months.The changes of clinical symptoms,SGA scores,renal function,serum albumin (Alb),hemoglobin (Hb),CRP,transferrin (TF),prealbumin (PA),red blood cell count (RBC),reticulocyte (absolute value of RET)were observed before and after the treatment.Results Compared with the control group,serum creatinine (Scr),24 h Upr were decreased significantly (P ＜0.01),the malnutrition status improved significantly,serum Alb and Hb increased significantly (P ＜ 0.05),the symptom scores and SGA scores reduced (P ＜ 0.05),CRP decreased significantly (P ＜ 0.05) in the treatment group.Conclusion Jianpi Bushen Digui Decoction can improve the malnutrition of patients,protect the renal function,and reduce the level of CRP.

Objective:To observe the effects of traditional Chinese medicine compound Tang Bikang on the expressions of Bax and JNK protein and Bax mRNA in sciatic nerve of diabetic rats.Methods:A total of 60 SD male rats were randomly divided into the control group,metheycobal group and low,medium and high dose of Tang Bikang groups,10 rats per group.The high fat diet coupled with the injection of small dose of streptozotocin (STZ) was used to induce the rat model of type 2 diabetes.The corresponding drugs were respectively given each group.After 16-week experiment,the rats were sacrificed and the unilateral sciatic nerves were harvested.The expressions of Bax protein were detected using immunohistochemical method.The expressions of JNK and p-JNK,and the mRNA expression of Bax were detected by Western blot and RT-PCR,respectively.Results:Compared with the control group,the expressions of Bax protein and mRNA were decreased significantly and the protein expressions of p-JNK and JNK were significantly increased in the model group (P＜0.05,P＜0.01).Compared with the model group,the expressions of Bax protein and mRNA were decreased significantly in medium dose of Tang Bikang group (P＜0.01,P＜0.05),the Bax mRNA expressions were significantly reduced in the low dose of Tang Bikang group (P＜0.05),and the Bax protein expressions were significantly reduced in the methycobal group (P＜0.01).Although the treatment of methycobal or the high dose of Tang Bikang reduced the protein and gene expressions of Bax,correspondingly,there were no statistical differences between the treatment groups and the model group.The treatments of methycobal and the low and high dose of Tang Bikang reduced the expressions of JNK protein (P＜0.01),and the treatments of methycobal and the middle and high dose of Tang Bikang decreased the expressions of p-JNK protein (P＜0.01).There were no statistical differences in the expressions of JNK and p-JNK protein between the model group and the treatment groups including the methycobal group and the high dose of Tang Bikang group.Conclusion:Traditional Chinese medicine compound Tang Bikang could suppress the transcription of Bax mRNA and protein,down-regulate the protein expression of p-JNK and JNK in sciatic nerve of diabetic peripheral neuropathy rats,which could be one of the targets of Tang Bikang exerting the nerve protective and analgesic effects.

目的:观察中药复方糖痹康对糖尿病周围神经病变(DPN)大鼠脂代谢和坐骨神经超微结构的影响.方法:采用高脂饲料和小剂量链脲佐菌素(STZ)诱发2型糖尿病大鼠动物模型,用不同剂量的糖痹康灌胃,并与甲钴胺对照,16周后腹主动脉取血及大鼠一侧坐骨神经,用电镜观察其超微结构,采用酶法测定大鼠血清总胆固醇(TC)和甘油三酯(TG);免疫比浊法测定大鼠血清高密度脂蛋白胆固醇(HDL-C)、低密度脂蛋白胆固醇(LDL-C);铜试纸显色法检测大鼠血清游离脂肪酸(NEFA).结果:与正常组比较,模型组HDL-C含量均显著降低(P＜0.01),TG、TC、LDL-C、NEFA均显著升高(P＜0.01).与模型组比较,糖痹康及甲钴胺组HDL-C的含量均显著升高(P＜0.01),TG、TC、LDL-C、NEFA含量均显著降低(P＜0.01).电镜结果显示,正常组大鼠坐骨神经横切面髓鞘结构完整、致密、均匀;模型组大鼠坐骨神经横切面髓鞘的板层结构发生严重分离,各层间排列紊乱,出现大量空泡及裂隙;各给药组坐骨神经中空泡及裂隙均显著降低,但髓鞘仍未恢复板层状结构,线粒体及粗面内质网结构正常,出现结构完整的雪旺细胞.结论:糖痹康能改善DPN大鼠血脂及降低其血清NEFA水平,同时其对坐骨神经髓鞘、轴索等具有修复作用.

Objective To explore the effects of Chinese herbal compound Tangbikang on the expressions of p38 MAPK of sciatic nerve and plasma TNF-α in diabetic rats. Methods Ten of the sixty male SD rats were selected randomly as normal group, and the rest were fed with high-fat diet and low-dosage STZ was used to induce type Ⅱdiabetic rat models. Model rats were randomly divided into model group, mecobalamine group and Tangbikang low-, medium-, and high-dosage groups, 10 rats in each group. Each medication group was intervened with relevant medicine. Rat unilaterals sciatic nerves were taken after 16 weeks. The content of TNF-α in plasma was determined by radioimmunoassay. Western blot method was used to detect the expressions of p38 and p-p38 MAPK protein of sciatic nerve. Results Compared with normal group, the expressions of p38 and p-p38 protein and content of TNF-αin model group significantly increase (P<0.05, P<0.01). Compared with the model group, the expressions of p-p38 protein and the content of TNF-α significantly decreased after medicine intervention in different doses Tangbikang groups and mecobalamin group (P<0.05, P<0.01). The expression of p38 protein in Tangbikang high-dose group significantly decreased (P<0.05), with statistical significance (P<0.05). Conclusion Tangbikang can reduce the expression of p38 and p-p38 MAPK protein of the rat sciatic nerve, and reduce the content of TNF-α protein in rat plasma, which may be one of the effective targets of neuroprotection and abirritation of diabetic peripheral neuropathy.

目的:观察中药复方糖痹康对高糖环境下大鼠坐骨神经雪旺细胞增殖的影响.方法:通过雪旺细胞株,建立高糖环境下大鼠雪旺细胞的细胞模型;用不同剂量的含药血清和正常血清培养基刺激24、48、72和96 h后,MTT法检测高糖环境下不同剂量的糖痹康含药血清对大鼠细胞增殖的影响.结果:与空白组比较,24、48、72、96 h后,50 mM GLU与75 mM GLU组细胞增殖程度均显著降低,但50 mM GLU与75 mM GLU组间并无差异;与50 mM高糖对照组比较,24、48 h后,弥可保及糖痹康1∶1、1∶2、1∶8组均可显著增高细胞增殖能力.结论:糖痹康组可明显改善高糖培养环境下雪旺细胞增殖活性,糖痹康低剂量组优于西药(弥可保)组,其在高糖培养的环境下,中医复方糖痹康可促进大鼠坐骨神经雪旺细胞的增殖,可能是其防治DPN的机制之一.

目的:观察中药复方糖痹康对高糖环境下大鼠雪旺细胞p38丝裂素活化蛋白激酶（p38 MAPK）、肿瘤坏死因子-α（TNF-α）及可溶性血管间内皮细胞黏附分子-1（s VCAM-1）表达的影响。方法:通过雪旺细胞株,建立高糖环境下大鼠雪旺细胞的细胞模型;用不同剂量的含药血清和正常血清培养基刺激48h后,采用放免法检测细胞上清中TNF-α的含量;ELISA法检测细胞上清中s VCAM-1的含量,Western blot法检测大鼠雪旺细胞p38和磷酸化p38丝裂素活化蛋白激酶（p-p38 MAPK）的表达。结果:与空白对照组比较,高糖对照组的s VCAM-1、TNF-α、p-p38 MAPK及p-p38 MAPK含量显著升高（P＜0.05,P＜0.01）;与高糖对照组比较,弥可保与糖痹康各剂量组上清中s VCAM-1、TNF-α、p38 MAPK及p-p38 MAPK的含量显著降低（P＜0.05,P＜0.01）。结论:糖痹康含药血清可下调在高糖环境下大鼠坐骨神经雪旺细胞p38 MAPK及其激活形式p-p38 MAPK蛋白表达,下调大鼠坐骨神经雪旺细胞上清中TNF-α的含量,可能是其DPN神经保护及镇痛作用靶点之一及下调大鼠坐骨神经雪旺细胞上清中s VCAM-1的含量,可能是其DPN神经保护作用靶点之一。

目的:观察中药复方糖痹康对糖尿病大鼠坐骨神经血管内皮生长因子(VEGF)蛋白及VEGF mRNA表达的影响.方法:SD雄性大鼠60只,随机选取10只为正常组,其余大鼠采用高脂饲料和小剂量链脲佐菌素(STZ)诱发2型糖尿病大鼠动物模型.造模成功后随机分为模型组,弥可保组,糖痹康低、中、高剂量组,每组10只.各组采取相应干预.16周后取大鼠一侧坐骨神经,用免疫组化法检测坐骨神经中VEGF蛋白的表达及采用RT-PCR方法检测坐骨神经组织中VEGF mRNA的表达.结果:与正常组比较,模型组VEGF蛋白及mRNA表达显著升高(P＜0.01);与模型组比较,弥可保组和糖痹康组VEGF蛋白及VEGF mRNA表达降低(P＜0.05,P＜0.01).结论:中药复方糖痹康能显著下调DPN大鼠坐骨神经中VEGF蛋白及基因表达,这些可能是其防治DPN的有效作用靶点之一.

Objective] To objective evaluate of clinical efficacy and safety of treatment of diabetic peripheral neuropathy (DPN) by Chinese herbal compound Tangbikang, the clinical trials were adopted by self-control. [Methods] The 35 DPN patients conforming to the diagnostic criteria, based on the basic treatment for blood pressure, blood glucose and blood lipid, were given Chinese herbal compound Tangbikang. After curing for 8 weeks, we measured some indicators, like traditional Chinese medicine (TCM) syndrome, laboratory examination and electromyography. [Results] After the treatment by Tangbikang, the conduction velocities of MCV and SCV was better than before, and the difference was significant (P<0.05). Security Index including blood glucose, glycosylated hemoglobin, blood lipid and blood pressure with normal limits, the difference was insignificant (P>0.05), and there were no obvious side effects whreh had been found during the treatment. [Conclusion] Chinese herbal compound Tangbikang could improve of symptom, the nerve conductive velocity and the diabetic peripheral neuropathy integralsobviously, and the total effective rate of the Tangbikang was 91.14%.

目的:慢性肾脏病(CKD)是一种临床综合征,由多种病因引起,疾病呈进展性,发病机制复杂.中医肾病学界通过多年临床实践证实,中医药在防治CKD中有一定的优势,其中慢性肾衰竭作为中医药的优势病种,在慢性肾脏病三级预防及一体化治疗中发挥着重要作用.通过中医对CKD病因病机、 证治规律及疗效评价的相关研究,总结慢性肾脏病中医治疗现状及存在问题,藉此提高临床诊疗水平.