目的 探讨代谢相关性脂肪性肝病(MAFLD)合并慢性乙型病毒性肝炎(CHB)患者的肾脏功能状况,并对影响肾小球滤过率(eGFR)的相关因素进行分析.方法 分别收集 MAFLD 组(n =141)和CHB-MAFLD组(n=144)患者的肝脏生化、肾脏生化等临床资料,利用eGFR对两组患者的肾脏功能进行评价,采用多因素logistic回归分析探讨肾功能受损的影响因素.结果 在符合纳入标准和排除标准的 285 例患者中,与MAFLD组对比,CHB-MAFLD组三酰甘油(TG)、总胆固醇(TC)、谷氨酰转肽酶(GGT)、血肌酐(SCr)、eGFR、大量饮酒史之间的差异有统计学意义(P＜0.05);CHB-MAFLD组出现SCr异常升高(16.67％vs 3.55％,x2 =13.418,P＜0.001)及肾功能受损(40.97％vs 12.77％,x2 =28.745,P＜0.001)的比例明显高于MAFLD组;多因素logistic回归分析提示性别、年龄、尿酸、合并糖尿病、合并高血压、合并CHB是影响患者肾功能的独立影响因素.结论 CHB-MAFLD患者存在亚临床型肾功能受损,可能比单纯MAFLD患者更易发生、发展早期肾功能受损.对于CHB-MAFLD患者,更应严格控制相关危险因素,预防慢性肾病的发生.

基于岭南地区代谢相关脂肪性肝病的病证特点,探讨运用黄芪治疗岭南地区代谢相关脂肪性肝病经验.认为脾虚阳弱、湿浊内蕴为发病之源,病初之期当用黄芪健脾暖土以伏虚火,升清温表以制湿浊,常用15～30 g,用药需递进施补,可伍太子参、白术、茯苓、防风等共奏培土制湿之效;气血郁滞,痰湿蕴热为病进之机,当取黄芪实脾荣肝、通阳行滞之性,常用30～60g,斡旋气机流行,通和中焦阳气,同时配伍柴胡、白芍、郁金等温凉共济;顽浊痼脂瘀结于肝,为病著之期,可夹湿、痰、热诸邪,黄芪需用至60～90g,以活血消脂,扶正祛邪,并配合山楂、决明子、路路通、泽泻等消脂降浊药.遣方时当根据不同季节特点配伍他药,调黄芪之升降,以顺应四时之性.

慢性乙型肝炎是我国主要的传染性疾病,中医对其防治有着鲜明的特色且疗效显著.池晓玲教授是全国第六批名中医药专家学术经验继承指导老师,广东省名中医,岭南名医,博士研究生导师,广东省中医院肝病科主任.池晓玲教授临床论治慢性乙型肝炎经验丰富,疗效显著,学术特点鲜明,尤其以运气辨治思想独具特色.现以池晓玲教授在辛丑年治疗慢性乙型肝炎为例,探讨池晓玲教授运用五运六气学说防治慢性乙型肝炎特点.

Ethnopharmacological relevance: The AnluoHuaxian pill (AHP) is a widely used patented medicine for chronic hepatitis B (CHB) patients with advanced fibrosis or cirrhosis that has been used in China for more than 15 years. However, data are lacking on whether monotherapy with AHP can be effective in CHB patients with alanine aminotransferase (ALT) levels less than 2 times the upper limit of normal (ALT<2ULN) and early liver fibrosis (F <= 2). Aim of the study: We aimed to investigate whether monotherapy with AHP improves liver histology in these patients. Materials and methods: In this double-blind, randomized, placebo-controlled trial, 270 CHB patients with ALT<2ULN and F <= 2 were treated in 12 hospitals in China. The patients were randomly assigned to an intervention (AHP) group and a placebo group at a ratio of 2:1. Of these 270 enrolled patients, 147 had paired liver biopsies. The primary end point was histological change after 48 weeks of treatment. Results: Per-protocol analysis revealed that the rate of histologic improvement in liver fibrosis patients in the AHP group was significantly higher than that in the placebo group (37.7% vs. 19.5%, P = 0.035) after 48 weeks of treatment, which was consistent with results from intention-to-treat and sensitivity analyses. Moreover, after adjusting for baseline characteristics, AHP was superior to placebo with respect to improving liver fibrosis (odds ratio [OR] = 2.58, 95% confidence interval [CI]: (1.01, 6.63),P = 0.049) and liver histology (OR = 3.62, 95% CI: (1.42, 9.20),P = 0.007). In noninvasive measurement of liver fibrosis (FibroScan (R)), the level of liver stiffness measurement (LSM) had decreased significantly at 48 weeks (5.1 kPa) compared with that at baseline (5.7 kPa) (P = 0.008) in the AHP group, whereas it did not decrease significantly in the placebo group. Cirrhosis developed in one patient in the placebo group but in no patients in the AHP group. No serious side effects occurred in the AHP-treated patients. Conclusions: Treatment of CHB patients who had ALT<2ULN and F <= 2 with the traditional Chinese medicine AHP for 48 weeks improves liver fibrosis. However, due to the short duration of treatment and the limited sample size of liver pathology, the long-term benefits of AHP in reducing fibrosis and the risk of cirrhosis and hepato-cellular carcinoma in these patients need to be further studied in the future.

目的:观察中医特色慢病管理对乙型肝炎肝硬化营养不良患者的影响.方法:选取2018年4月至2019年5月从广东省中医院肝病科出院的乙型肝炎肝硬化肝肾阴虚型营养不良患者60例为研究对象,按照随机数字表法分为对照组和中医慢病管理组,每组30例.对照组患者给予常规的中西医内科治疗方案,中医慢病管理组患者在对照组的基础上给予个性化的中医健康调养方案.干预12周后观察两组患者在主观综合营养评估(SGA)、营养相关生化指标(血清白蛋白、前白蛋白、总胆固醇)、中医症状积分及生活质量评分(SF-36)是否存在差异.结果:干预12周后,两组患者的SGA评分均较治疗前降低,但中医慢病管理组的SGA评分较对照组降低更明显(P<0.05).在营养相关的生化指标方面,干预后中医慢病管理组患者的血清白蛋白、前白蛋白水平较前明显升高(P<0.05),而对照组患者干预前后无明显变化(P>0.05),但两组患者的总胆固醇水平均较干预前无明显变化(P>0.05).干预后两组患者的中医症状和生活质量都有所改善,但中医慢病管理组患者的中医症状和生活质量改善更明显(P<0.05).结论:在常规中西医内科治疗的基础上联合中医特色慢病管理方案可有效改善乙型肝炎肝硬化营养不良患者的营养状态,减轻患者临床症状,提高患者生活质量.

Background: In recent years, more and more studies revealed that liver fibrosis progression could happen at early stage in chronic hepatitis B (CHB) patients. However, there is no anti-fibrotic agent available at present in modern medicine.He-He-Shu-YangParticles (HHSYP) and Anluohuaxian Pills (AHP)are two commonly used Traditional Chinese Medicine (TCM) agents for liver fibrosis, but there is no data of them for early liver fibrosis(F1 or F2) in multicenter, randomized controlled trial. Therefore, the aim of this study is to evaluate efficacy and safety ofHHSYP plus AHP for early liver fibrosis in CHB patients. Methods/design: For the 72-week randomized controlled study, 480 CHB patients with early liver fibrosis are randomly assigned at a 2:1 ratio to two groups: the intervention group and the placebo group. The intervention group was treated with HHSYP plus AHP. The placebo group was treated with placebo of HHSYP and AHP. The primary end point is the histological change after 72-week treatment. Discussion: Although previous studies have confirmed the anti-fibrosis efficacy of HHSYP and AHP in CHB patients, the efficacy and safety of their combination treatment for early liver fibrosis is still not clear.Therefore, this will be the first multicenter randomized trial to prove the efficacy and safety of combination TCM treatment of HHSYP and AHP for early liver fibrosis, which will use histological changes as the primary end point. This will provide reliable data for the TCM combination treatment of early liver fibrosis and might give a new direction for further international studies on liver fibrosis. Ethics and dissemination: This study protocol was approved by the Ethics Committee of Guangdong Provincial Hospital of Chinese Medicine (BF2018-175-01) and all other participating centers (Project number2018ZX10725506-003).The study findings will be published in peer-reviewed journals and presented at the national and international conferences. Trial registration: Chinese Clinical Trial Registration: ChiCTR1900025897, Registered:13 September 2019, http://www.chictr.org.cn/edit.aspx?pid=40222&htm=4

池晓玲教授为岭南名医,广东省名中医,广东省中医院肝病科学术带头人,从事中医肝病临床及教学工作近40年,首创并推广实施多维立体系列疗法体系治疗肝病,体系中的慢病管理系列具有鲜明的中医特色,临床实践取得良好疗效.笔者有幸随师侍诊,体会深刻,故将其对慢性乙型肝炎(CHB)的慢病管理思想总结如下.

肝郁脾虚证是慢性肝病的主要证候,疏肝健脾法是其重要治法,在临床广泛用于病毒性肝炎、肝硬化、脂肪肝等疾病的诊治中.疏肝健脾法属于中医"和"法的范畴,是根据五行相克次序确立的一种治法.现就疏肝健脾法的理论根源及在不同慢性肝病中的应用进行探讨.

运气学说是探讨自然变化的周期性规律及其对生命、疾病影响的一门学说,承载了中医学最基本的理念、认知方法及思维模式.近20年来笔者团队一直致力于将运气思想应用于肝病的临床实践,取得了良好的疗效.文章对多维立体系列疗法体系的构建、预测气候变化、预测肝病的发生发展并制定预防法则、创立肝病时复诊治理论、肝病治疗的遣方用药、肝病外治法的临床应用、肝病中医特色慢性疾病管理等方面运用运气学说的经验进行总结,为构建全方位全生命周期的肝病中医诊疗模式提供参考.

The aim of this study was to determine if microRNA (miRNA) expression is different among chronic hepatitis B (CHB) patients with early liver fibrosis classified according to traditional Chinese medicine (TCM) syndromes. Eighteen CHB-fibrosis patients and 12 CHB patients without fibrosis were enrolled. The CHB-fibrosis group included 9 patients with the TCM syndrome of Ganyu Pixu Xueyu (GYPXXY), characterized by liver stagnation, spleen deficiency, and blood stasis, and 9 patients with the TCM syndrome of Qixu Xueyu (QXXY), characterized by deficiency of qi, blood, and blood stasis. Agilent miRNA microarray was performed first in liver specimens to determine whether miRNA expression is different in patients with these two TCM syndromes of CHB-fibrosis. Gene Ontology (GO) analysis and KEGG analysis were applied to determine the roles of the differentially expressed miRNAs. QRT-PCR was performed to validate the Agilent miRNA microarray results. Compared with GYPXXY patients, 6 differentially expressed miRNAs were upregulated (miR-144-5p, miR-18a-5p, miR-148b-3p, miR-654-3p, miR-139-3p, and miR-24-1-5p) and 1 was downregulated (miR-6834-3p) in QXXY patients. According to qRT-PCR data, miR-144-5p and miR-654-3p were confirmed as upregulated in CHB-liver fibrosis patients compared to CHB patients without fibrosis, whereas the other 4 miRNAs were not significantly different. More importantly, miR-654-3p was confirmed to be significantly upregulated in QXXY patients compared with values in GYPXXY patients, whereas no significant difference was found in miR-144-5p. Moreover, the pathways of central carbon metabolism in cancer and cell cycle related to miR-654-3p and the target genes of PTEN and ATM were found to be different between QXXY patients and GYPXXY patients. These results indicate that there are different miRNAs, pathways, and target genes between QXXY patients and GYPXXY patients. However, due to the limited sample, whether miR-654-3p and the target genes PTEN and ATM could be molecular markers to differentiate TCM syndromes could not be established.

目的:探讨广州地区2008年至2019年运用五运六气学说预测的气象变化与实际气象变化的吻合程度,为临床应用运气学说提供依据.方法:在回顾既往运用运气学说预测2008年至2019年主要气象变化的基础上,收集、整理广州地区相应时段的逐日累计降水量、平均气压、平均相对湿度、平均气温、平均风速等气象资料,并与既往运用运气学说分别从岁运、司天之气、在泉之气预测2008年至2019年的主要气象资料进行一致性比较.结果:根据岁运预测12年的气象变化,与实际气象资料完全符合率为90.48％,基本符合率达100％;根据司天之气预测的气象变化,与每年上半年实际气象资料相符率仅25％,与每年全年实际气象资料相符率为50％;根据在泉之气预测的气象变化,与每年下半年实际气象资料相符率为58.33％,与每年全年实际气象资料相符率仅41.67％.结论:运用运气学说从岁运的角度可预测每年主要的气候变化规律,而更具体的实际的气象变化的预测还有待进一步深入研究.

Bicyclol, the most commonly-used liver hepatoprotective drug in China, is often selected to control disease progression in CHB patients who refuse anti-viral treatment. However, data on histological changes after bicyclol treatment in these patients are scarce. Therefore, this study has been conducted to find out whether bicyclol has good benefits of histological improvement in CHB patients who refuse anti-viral agents. The demographic, clinical and pathological data were collected from CHB patients who received bicyclol from January 2010 to June 2016. Improvement in liver inflammation or fibrosis is defined as at least one-grade or one-stage decrease as measured by the Scheuer scoring system. Thirty patients treated with ETV for 48 weeks were chosen as a control group to compare the histological improvement between bicyclol and entecavir (ETV) after 48-week treatment. A total of 123 patients with CHB treated with bicyclol were included in this study. Paired liver biopsies were performed in 70 patients. Inter-biopsy interval was 17.44 ± 8.90 months (12–60 months). As shown by facts, 41.4% patients achieved liver inflammation improvement, while only 10.0% patients showed liver inflammation progression after bicyclol treatment. In regarding to liver fibrosis, as shown by facts, 28.6% patients achieved fibrosis improvement. More importantly, It was found that the proportions of patients with liver inflammation and fibrosis improvement were both not significantly lower than those in ETV group (53.3% vs 63.3 and 36.7% vs 43.4%). Most of patients (82.4%) with elevated baseline ALT became normal after bicyclol treatment. More importantly, as shown by the multi-variate analysis, the treatment course of bicyclol was an independent factor for liver inflammation improvement. With the HBeAg status adjusted, ALT and HBV-DNA quantity, the odds ratio (95% confidence interval) of patients with ≥48-week treatment was 5.756 (1.893,17.500) when compared with patients via < 48-week treatment. Bicyclol can improve liver inflammation and the ALT normalization rate of CHB patients, especially when the treatment course is prolonged. This has confirmed that bicyclol could control hepatitis activity, which might be a good choice for CHB patients who refuse anti-viral treatments.

中医运气学说是以大系统的方法,把古代天文、历法、气象、物候、逻辑、医学、生物学等内容综合在一起,纳入一个大系统来进行考察,把疾病流行周期和历法结合起来,通过“五六相合”的谐调周期,巧妙地建立了系统控制的程序.本研究通过对北京和广州地区1959年(己亥年)、1989年(己巳年)的逐日平均风速、平均相对湿度、平均气温、累计降水量、平均气压气象资料进行整理及比较,从气象数据分析己亥年与己巳年的运气异同,为己亥年运用运气学说防治疾病特别是慢性肝病提供依据.

The rich Chinese historical literature has created extremely favorable conditions for the study of traditional Chinese medicine.Doctrine on yunqi is one of the most important basic theories of traditional Chinese medicine (TCM),it is a copy of precious medical legacy for the ancients to conjecture the climatic change,predict the vicissitude of many diseases and guide for disease diagnosis and treatment nursing.Based the research on the literature of ancient Chinese infectious diseases,this article has a discussion on the characteristics of yunqi in Wuxu year,also exploration of TCM diagnostic and therapeutic regularities to chronic hepatopathy,for the purpose of providing a better foundation for the TCM diagnostic,therapeutic and health care of chronic hepatopathy in 2018,the year of Wuxu.

OBJECTIVE:To demonstrate the potential to treat non-alcoholic fatty liver disease (NAFLD) with colon hydrotherapy (CHT) plus Traditional Chinese Medicine (TCM).METHODS:A total of 20 patients were enrolled into the study and received CHT with TCM for 2 weeks. Body mass index (BMI) and levels of serum triglycerides (TG) and total cholesterol (TC) were compared between pre-treatment and post-treatment.RESULTS:Two-week treatment with CHT plus TCM significantly lowered BMI and reduced blood lipids. BMI decreased from 29.5 4.3 to 25.4 1.0, while mean TG levels decreased by 0.70 mmol/L on average from baseline and mean TC levels decreased by 0.37 mmol/L. Forty-five percent of patients exhibited TC decreasing by more than 10% from baseline and 25% of patients exhibited TC decreasing by more than 20%. Sixty percent of patients exhibited TG decreasing by more than 20% and 20% of patients exhibited TG decreasing by more than 40%. However, high-density and low-density lipoprotein cholesterol levels did not change significantly after intervention. No serious adverse events were reported.CONCLUSION:Our findings suggest that CHT plus TCM to treat NAFLD is promising and it might be a new treatment strategy for management of NAFLD.

目的:对门诊非酒精性脂肪肝患者进行中医体质辨识,分析该病中医体质分布情况,并进行中医健康管理、分析干预效果.方法:对健康调养门诊确诊的312例非酒精性脂肪肝患者进行资料填写,严格按照中医体质量表及《中医体质分类与判定》标准,并结合望、闻、问、切综合判断患者体质后给予中医特色的健康管理或运动、饮食调养后进行疗效比较.结果:回收问卷312份,偏颇质占276/312(88.46％),平和质占36/312(11.54％);偏颇体质中,痰湿质占120/312(38.46％);在脂肪肝体质类型中,痰湿质、湿热质明显高于其他体质类型;患病率男性多于女性.女性随年龄增长,患病率逐渐升高,尤其是进入更年期后,女性患病率明显高于男性(P＜0.05).治疗组给予中医健康管理2个月后,总有效率为97.3％,与对照组的96.1％比较,差异无统计学意义(P＞0.05).结论:非酒精性脂肪肝患者中痰湿质人数最多,中医预防保健措施进行健康管理效果显著,与对照组疗效相当.