1. Summary of medical history Male, 67 years old. He was admitted to the hospital on February 8, 2005 with the main reason of “recurrent swelling of both lower limbs for 7 years, aggravated by weakness for 2 months”. The patient was diagnosed with “hypertension stage III, hypertensive benign renal arteriosclerosis” and was given Beijing Antihypertensive 0, compound Robitussin, prazosin hydrochloride and nifedipine extended-release tablets to lower blood pressure. In April 2003, he went to a hospital for blood Cr133.1μmol/L, Ccr81.98ml/min, BUN8.6mmol/L, 24-hour urine protein quantification 0.398g, ultrasound showed diffuse heterogeneous changes in both kidneys, and was diagnosed as He was diagnosed as “chronic renal insufficiency and renal hypertension”, and was treated with antihypertensive therapy and given Jinshui Bao, urinary toxicity Qing and Chinese herbal medicine orally, but the edema was sometimes mild and sometimes heavy. 2 months ago, the edema of both lower limbs increased after exertion and weakness was obvious, so he was admitted to our hospital after outpatient treatment with tonics was ineffective. At the time of admission, he had swelling of both lower extremities, lumbar pain, weakness, coughing from time to time, and was able to pass stool once or twice a day and urinate twice at night. He had a history of chronic gastritis for more than 50 years, and a history of smoking for more than 40 years, up to 2 packs/day. He had a history of chronic gastritis for more than 50 years and a history of smoking for more than 40 years. The left upper lung breath sounds were coarse, and no obvious dry and wet rales were heard. There was no enlargement of the cardiac border on percussion, the heart rate was 76 beats/min, the rhythm was uniform, and grade III/VI systolic murmurs could be heard in the apical region and the aorta and pulmonary artery auscultation areas. The abdomen was soft, the liver and spleen were not palpable under the ribs, there was no percussion pain in both kidney areas, and both lower limbs were mildly edematous. The tongue is light and dark, fatty with tooth marks on the sides, slightly yellowish and greasy tongue coating, and smooth pulse. Laboratory tests: blood RT: RBC3.79×1012/L, WBC4.70×109, HGB124.0g/L, N67.4%, L26.4%; urine RT: PRO-, GLU-, ERY10/UL; blood biochemistry: GLU5.4mmol/L, TP65g/L, ALB38g/L, CHO3.7mmol /BG, TG1.51mmol/L, ALT11U/L, AST12U/L, Cr122μmol/L, BUN8.2mmol/L, UA304mmol/L, Ca2.1mmol/L, P1.03mmol/L. Ultrasound of both kidneys: right kidney 8.0cm×3.5cm, cortical thickness 0.8cm, left kidney 10.5 Chest plain film: no abnormality was found. Electrocardiogram: T wave was low and flat. Diagnosis: Chinese medicine diagnosis: edema (spleen and kidney qi deficiency, dampness and stasis); Western medicine diagnosis: chronic renal insufficiency in compensatory stage, renal hypertension. Treatment: Because the primary cause of chronic renal failure was unknown and the size of both kidneys was obviously asymmetrical, renal artery stenosis was suspected and percutaneous renal arteriography was performed on March 17, 2005. Combined with the results of renal arteriography, a case discussion was held on March 18, 2005 to clarify the diagnosis and decide the next step of treatment. The patient was admitted to the hospital mainly because of “recurrent swelling of both lower extremities for 7 years, aggravated by weakness for 2 months”, which was diagnosed as edema in Chinese medicine. Edema refers to the retention of water in the body and flooding the skin, causing swelling of the head, face, limbs, abdomen and back, and even the whole body. The main point of identification of edema is to distinguish yin water or yang water. The onset of edema is more urgent, and it occurs within a few days. The edema mostly starts from top to bottom and spreads to the whole body, with the skin of the swollen area being taut and shiny, and the sunken area being raised when pressed, and it is accompanied by superficial, heat and actual evidence such as irritable heat, thirst, redness of urine and constipation. Feng Shui and Pishui in the book “Jin Kui Yao” belong to this category. Yin Shui is mostly caused by deficiency of the spleen and kidneys and unfavorable Qi transformation. Edema mostly occurs gradually, accumulates over time, or comes from the transformation of yang shui. The edema mostly starts from the bottom and goes up, followed by the whole body, the skin at the swollen area is loose, and the depression is not easily recovered when pressed, or even like mud when pressed. This is the type of edema that is found in the book “Jin Kui Yao”. The patient’s edema started slowly, with edema of the lower extremities as the main cause, so it belongs to the scope of Yin Shui. In addition to edema, the patient has back pain, weakness, frequent nocturnal urination, a light and dark tongue, a fat tongue with teeth marks on the sides, a slightly yellowish coating on the tongue, and a thin and slippery pulse. Chinese medicine identifies this as deficiency of kidney qi and stagnation of water-dampness. Treatment is to tonify the kidney and benefit the Qi, invigorate the blood and promote the flow of water. Prescription: Radix Angelicae Sinensis and Paeoniae San, plus or minus. Prescription: Raw Astragalus membranaceus 15g, Radix Angelicae Sinensis 15g, Rhizoma Chuanxiong 12g, Radix et Rhizoma Paeoniae 12g, Radix et Rhizoma Polygonatum 15g, Poria 15g, Radix zedoariae 15g, Plantago lanceolata 15g, Rhizoma macrocarpa 15g, Rhizoma dongjiao bark 15g. Based on the results of renal arteriogram, ischemic kidney disease can be diagnosed. Resident physician Zhao Yu: The TCM diagnosis and evidence analysis basically agree with Dr. Quan Hong’s analysis. This patient has had recurrent episodes of edema for 7 years, which are difficult to heal, and her tongue is pale and dark. Therefore, in addition to deficiency of kidney qi, special attention should be paid to the relationship with stasis of blood, because stasis of blood and unfavorable water channels in the Sanjiao can often make the edema stubborn and difficult to heal. Blood evidence theory. Yin and Yang, Water and Fire, Qi and Blood” says: “Water and Fire, Qi and Blood, are certainly opposites, but they are also mutually dependent. Therefore, the water disease is tired blood …… stasis blood into water, also developed edema, is the blood disease and water”, indicating that water can disease blood, blood can disease water. Therefore, the prescription should increase the use of blood activating and stasis removing drugs, such as Zeilan, peach kernel, safflower, etc., to achieve the effect of blood moving water also moving. According to the results of renal arteriogram, his right renal artery stenosis at the beginning of the main trunk, the stenosis range is about 1M, the degree of stenosis is more than 75%, the blood creatinine is increased, accompanied by hypertension, can be diagnosed as ischemic kidney disease. It is generally accepted that the so-called chronic ischemic kidney disease is a chronic kidney disease with reduced glomerular filtration rate and renal insufficiency due to renal artery stenosis or obstruction (≥ 60%) and significant changes in renal hemodynamics. Atherosclerosis, fibromuscular dysplasia and aortitis are common causes of renal artery stenosis, with atherosclerosis predominating in older patients and aortitis and fibromuscular dysplasia in younger patients. In recent years, with the aging of the population, atherosclerotic renal artery stenosis has become an important cause of chronic renal failure, accounting for approximately 12% to 24% of the dialysis population. Therefore, it is of great importance to enhance the understanding of chronic ischemic kidney disease, especially atherosclerotic renal artery stenosis. For the treatment of ischemic kidney disease, in addition to the current Chinese medicine evidence-based treatment and antihypertensive treatment, whether interventional therapy can be performed, my personal knowledge is limited, and the department has not carried out this work before, so I would like to ask for instructions from the senior physicians. Attending physician Wang Li: Dr. Zhao Yu talked about the relationship between edema and blood stasis, and in the treatment of kidney disease in Chinese medicine, special attention should be paid to activating blood stasis and clearing heat and dampness. Now, I would like to talk a little bit about my personal understanding on the treatment of blood circulation and stasis. Stasis of blood in TCM refers to the stagnation of blood in the veins before it leaves the body, or the blood in the veins is blocked by phlegm and fire or dampness and heat. It is generally believed that the pathogenesis of stagnant blood includes the entry of evil toxins into the camp, or external obstruction of the pulse channels; improper handling of bleeding and retention of residual blood; postpartum malodorous dew; contusion of the veins and collaterals; and other diseases of Qi and blood. The treatment of blood stasis varies depending on the condition, for example, if blood stasis is internal, blood stasis can be broken by using Tao Ren Cheng Qi Tang or the like; if blood stasis is blocked, blood stasis can be invigorated by moving Qi and invigorating blood, or invigorating blood stasis by using Blood Mansions and Stasis Tang or the like; if blood stasis is caused by cold clotting in the meridians, blood stasis can be invigorated by warming the meridians and invigorating blood by using Wen Jing Tang or the like. In TCM kidney diseases, the main causes of blood stasis are “deficiency causing blood stasis”, “water stasis and mutual stasis”, “prolonged illness and blood stasis”, etc. Therefore, benefiting Qi and invigorating Blood, invigorating Blood to promote water circulation and tonifying deficiency to invigorate Blood, etc. Therefore, benefiting Qi and invigorating Blood, invigorating Blood and promoting Blood circulation, and tonifying deficiency and Blood have become common methods in the treatment of kidney disease. The prescription for this patient has two suggestions: first, increase the dosage of qi tonic products such as astragalus to benefit qi and invigorate blood; second, add some blood-boosting and water-relieving products such as motherwort and panax quinquefolium. The treatment of atherosclerotic renal artery stenosis mainly includes pharmacotherapy, interventional and surgical treatment. Pharmacological treatment focuses on controlling hypertension caused by renal artery stenosis, reducing the impact of hemodynamic changes on renal function, and reversing or delaying the progression of renal function. With stenosis of one renal artery, antihypertensive therapy is mostly ineffective in the diseased side of the kidney but can benefit the contralateral non-angiopathic kidney; therefore, pharmacological treatment should be preferred for mild, manageable hypertension or for those with high surgical risk due to diffuse atherosclerotic complications. The commonly used antihypertensive drugs are calcium channel antagonists and beta-blockers, etc. Diuretics are used with caution, and angiotensin-converting enzyme inhibitors and angiotensin-converting enzyme receptor antagonists are prohibited. It should be noted during pharmacotherapy that in patients with severe stenosis of both renal arteries or isolated kidneys with renal artery stenosis, the reduction of blood pressure often leads to a decrease in renal function, and pharmacotherapy is more difficult. The patient has indications for interventional treatment, and it is recommended that percutaneous transluminal right renal artery angioplasty be performed in consultation with the catheterization laboratory. Attending physician Li Shen: The patient has a deficiency of qi and is unable to move blood, resulting in stagnation of veins and vasculature; a deficiency of qi without consolidation results in frequent urination, a pale tongue and a thin pulse are also evidence of qi deficiency and blood stasis. Therefore, this patient’s blood stasis is mainly due to Qi deficiency and blood stasis, and the treatment should be to tonify Qi, invigorate Blood and promote blood circulation. Tonic Yang Returning Five Tang is a representative formula for treating Qi deficiency and blood stasis. The formula emphasizes the use of Huang Qi to tonify the Qi of the spleen and stomach, so that the Qi can flourish, the blood can flow, and the stasis can be removed. Radix Angelicae Sinensis is good at invigorating blood and has the advantage of resolving blood stasis without harming the blood, which is the subject herb. Rhizoma Chuanxiong, Radix Paeoniae, Rhizoma Peach, and Rhizoma Red Flower help Angelica to invigorate blood circulation and remove blood stasis, while Radix et Rhizoma Di Long opens the meridians and activates the channels. The combination of this formula is characterized by a large number of Qi tonic and a small number of Blood invigorating herbs, so that Qi flourishes and Blood moves, invigorating Blood without harming the proper function of tonifying Qi and invigorating Blood to open the channels. Renal artery revascularization is the most feasible method to restore blood flow to the kidney, which mainly includes surgical and percutaneous interventional procedures. Studies have shown that surgical intervention is not only traumatic, but also has a high patient mortality rate, which makes it difficult to carry out widely. Compared with revascularization surgery, interventional treatment does not require general anesthesia, is less traumatic, has shorter hospitalization dates, can be repeated, and has similar therapeutic effects to surgery, therefore, it has been more commonly carried out in recent years and has become the first choice for the treatment of renal artery stenosis. Interventional treatment includes percutaneous transluminal renal artery angioplasty and renal artery stenting, which interventional treatment method is more suitable for this patient. Dr. Zhanyongli, chief physician: According to the diagnostic criteria for blood stasis evidence established by the Beijing International Conference on Blood Stasis Evidence in October 1988, blood stasis evidence can be diagnosed if one of the following items is present: purple tongue or petechiae; typical astringent pulse or no pulse; pain with a definite location; abdominal evidence of blood stasis; accumulation of blood; blood away from the menstrual cycle (bleeding or traumatic stasis); skin and mucous membrane petechiae with abnormal veins; dysmenorrhea with black color and blood clots or amenorrhea; skin nail fault; hemiplegia and numbness; stasis of blood and mania; physical and chemical examination with blood circulation stasis. In the course of clinical practice, we have learned that, from the perspective of TCM internal medicine, the most common indicator for diagnosing stasis of blood is a purple and dark tongue or petechiae. The TCM diagnosis of this patient includes both the principal deficiency and the symptomatic deficiency from the overall analysis. The main manifestation of this deficiency is spleen and kidney qi deficiency; the main manifestation of the symptoms is stasis of blood and damp-heat. The main cause of blood stasis is Qi deficiency and weak blood flow, while Damp-Heat and Blood stasis intertwine to further aggravate blood stasis. Therefore, its prescription should include tonifying Qi, invigorating Blood, and relieving Dampness. The selected formula is agreed to be treated with the addition and subtraction of tonifying Yang and Returning Five Soup as the main treatment. Tonic Yang Returning Five Tang is a representative formula of the theory of Qi deficiency and Blood stasis created by Wang Qingren in the Qing Dynasty. Although this formula is mainly used for the treatment of post-stroke, in fact many Qi deficiency and Blood stasis symptoms can be treated with this formula. Many modern studies have shown that this formula has the function of inhibiting platelet aggregation and thrombosis, anticoagulation, lowering blood lipids, dilating blood vessels, increasing blood flow, etc. It is widely used in clinical practice and is a treatment for different diseases. In the original formula of Yang Replenishing Five Soup, the dosage of Astragalus is 120 grams. In actual use, we can start with 30-60 grams and gradually increase the dosage when the effect is not obvious. But in this formula, the benefit of qi and blood circulation should be given equal importance, and at the same time, some heat-clearing and dampness-relieving products such as plantain should be used to benefit qi, blood circulation and dampness. According to the criteria established by the American Heart Association, percutaneous transluminal renal arterioplasty and/or arterial stenting can be performed when the following conditions are met: unilateral or bilateral renal artery stenosis >50% with or without mild, moderate or severe hypertension, with or without mild or moderate renal impairment; or transrenal stenosis lesion pressure gradient systolic pressure >20 mmHg, mean pressure >10 mmHg. 10 mm Hg. However, the following conditions are contraindicated for intervention: history of contrast allergy; presence of severe renal insufficiency, such as endogenous creatinine clearance.