Chronic renal failure is the end stage of many chronic kidney diseases, because the excretory function of the kidneys is severely impaired, resulting in nitrogen and other metabolic wastes being stored in the body, and causing imbalance of water, electrolytes and acid-base balance, the main clinical manifestation is the critical syndrome of self-intoxication, i.e. uremia. According to the statistics of Beijing, 96 people/million people die from kidney disease every year, thus seriously endangering people’s health. Although the application of hemodialysis, peritoneal dialysis and renal transplantation has opened up new ways for the treatment of advanced chronic renal failure, medical costs are very expensive and there are still a considerable number of patients with early and mid-stage chronic renal failure who need active treatment. Through nearly 30 years of clinical practice, the author experienced that if Chinese medicine is properly regulated, it is beneficial to alleviate the disease, improve the patient’s quality of life, delay the process of renal failure, thereby prolonging the patient’s life, the experience is described below.
I. Chinese medicine disease name
Although there is no term of “chronic renal failure” in Chinese medicine, the diseases described by “retention of urine”, “kidney wind” and “guan ge “The clinical manifestations of chronic renal failure are very similar to those described in ancient literature. For example, in Su Wen? The Discourses on the Transmission of Diseases of the Specimen: “When the bladder is sick, the urine is closed.” Ling Shu? The book of this transmission: “The Sanjiao …… real is the retention of urine.” And Su Wen? The strange disease theory: “There is a disease pang, such as water-like, cut its pulse big tight, body without pain, the shape is not thin, can not eat, eat less …… disease born in the kidney, called the kidney wind. Kidney wind and can not eat, good fright, fright has been, the heart gas impotent people die.” The Treatise on Typhoid Fever? The second of the Ping pulse method: “Guan is not allowed to urinate. If you do not have the right to take a bath, you will not be able to take a bath.” In the early 1980s, through the compilation and study of TCM disease names, the author concluded that the TCM disease name of chronic renal failure is more appropriate as it highlights the clinical characteristics reflected by the pathological mechanism of chronic renal failure at the end stage, due to the extreme deficiency of the central organ, resulting in the loss of the elevation and elevation of qi, and the congestion of the three jiao. At the same time, Guange has been considered a difficult and serious disease by medical practitioners for many generations, which is of some significance for judging the prognosis.
Second, the etiology and pathogenesis
The etiology and pathogenesis of this disease has been a matter of opinion for generations of physicians. As Chao Yuanfang pointed out in the Treatise on the Origin of the Diseases: “Guange is …… caused by the disharmony of yin and yang gas, and the failure of Ying and Wei. The yin and yang are both strong, shall not phase glory, said Guange.” Li Dong Yuan in the “Secret Collection of the Orchid Room” that “the disease is related, there is a grid …… are evil heat for the disease also.” Zhang Zihe discusses that the disease is caused by the inability of the Sanjiao restraint, that is, congestion and obstruction. Zhu Danxi considers it to be phlegm obstruction. Zhang Jinyue in the “Jing Yue Quanshu” said, “All those who see this, there is always alcohol and sex to hurt the kidneys, lust to hurt the essence, so that the Yang does not guard the house, so the pulse floating qi dew hyperactivity so, this is the true yin defeat exhaustion, the sea of yuan without roots, is sincere hyperactive dragon has the image of regret, the most dangerous wait also.” Emphasis on the deficiency of kidney essence as the focus of its pathogenesis, mainly related to alcohol, sex and lust. Li Yongcui, in his “Treatment of Evidence and Remedies”, believes that the pathogenesis of Guange is “the congestion of the three jiao by turbid evil and the failure of the right qi to rise and fall.” Shen Jin’ao pointed out that guan ge is caused by cold qi blocking the chest and heat qi closing the dantian. Chen Shiduo had a unique understanding of the pathogenesis of the disease, believing that the main cause was the loss of drainage of liver and gallbladder qi, resulting in the blockage of qi throughout the body. He Lianchen, on the other hand, believes that the drowning poison enters the blood and the blood poison goes to the brain.
Taking into account the relevant discussions of previous sages, on the basis of in-depth study and understanding, combined with clinical practice, I believe that the etiology of chronic renal failure has both primary and causal factors. The main cause is mostly due to deficiency of the spleen and kidneys, which is related to congenital deficiency, dietary disorders, internal injuries of the seven emotions, long-term illnesses and overwork, and other factors that deplete the vital energy. In particular, the kidney energy is exhausted, and the dampness and turbidity are mainly caused by the failure of the division of the clearing and secretion of turbidity. The causative factors are external evil and overwork.
Regarding the characteristics of the pathogenesis of chronic renal failure, the author believes that it can be summarized in four words, namely “complex”. It is reflected in the following aspects: from the positive to the evil to analyze the positive deficiency of the evil real, mixed with the real deficiency. There are differences in deficiency of Qi, Blood, Yin and Yang. However, the author found through clinical observation that, due to the mutual root relationship between qi, blood, yin and yang, and chronic renal failure, often yang (qi) loss and yin or yin loss and yang (qi), and eventually become the most common deficiency of both qi and yin. There are external evil, water stoppage, dampness, blood stasis, wind movement, and Yang Ming internal deficiency. The mechanism of occurrence is due to deficiency, because “Wei Qi out of the lower jiao”, chronic renal failure patients with kidney deficiency exhaustion, the Wei Qi will be deficient, the muscle surface is not solid, vulnerable to external invasion; and the kidney is the main water, the Division of the two stools, kidney deficiency, no power of gasification, the two stools out of order, resulting in the retention of turbidity, water and dampness flooding as a problem, and dampness can be heat, cold, and the difference. Chronic renal failure has a long course, “long term disease into the complex”, the Qi deficiency handsome blood without the right to cause internal obstruction of blood stasis.
From the analysis of the location of the disease, the organs involved are also more, if the water overwhelms the heart, there will be palpitations and chest tightness; dampness and turbidity on the dry spleen and stomach, affecting the stomach and spleen transport, lifting and lowering, there is vomiting, nausea, loose stools or dry knots; earth failure and wood thieves, liver wind within the movement, there can be limb convulsions, dizziness of the head and eyes; repeated external evil, lung congestion, resulting in fever, coughing and sore throat symptoms; kidney yin loss, kidney qi exhaustion, essence and the main function of water When the kidney yin is depleted and the kidney qi is exhausted, the functions of essence storage and water control are derelict.
When analyzed in terms of the cold and heat properties of the disease, it is often a mixture of cold and heat.
Based on the above, the pathogenesis of chronic renal failure is a combination of deficiency, cold and heat, and a wide range of disease locations, which makes clinical treatment difficult. However, the author believes that among the three pairs of pathological organs, the deficiency is the center of gravity, and the rest can basically be subordinated to this pair of relationships.
Clinical staging in Chinese medicine
In view of the fact that the TCM pathogenesis of chronic renal failure is positive-deficiency and evil-reality, and that there are differences in the course of the disease in terms of the priority of deficiency and the urgency of the symptoms, the author put forward the academic viewpoint of TCM clinical staging of the disease in 1984, and divided the disease into two stages: the deficiency stage and the chronic renal failure stage.
1, the deficiency stage refers to this stage of the patient’s clinical manifestations are dominated by a school of deficiency symptoms, the pathogenesis is characterized by the deficiency of positive qi, as to whether it belongs to qi deficiency, yang deficiency, yin deficiency, qi-yin two deficiencies, yin-yang two deficiencies is subject to further identification, the diagnostic criteria are as follows: ① The patient’s clinical manifestations are dominated by deficiency symptoms, such as fatigue, palpitation, shortness of breath, especially when moving, dizziness, tinnitus, fear of cold or five heart bothering heat, waist and knee Soreness and weakness, heel pain, spontaneous sweating or night sweating, dry mouth and tongue, etc. (2) Atrophy or pallor or obscurity, pale tongue with tooth marks, greasy moss or dry tongue with little moss, floating and weak pulse or fine count. ③ Urine taste in the mouth or mild nausea, poor appetite. ④ Past history of guanxi may be present.
The clinical manifestation of the patient has the typical characteristics of Guange disease of lower Guange and upper Guange, and the disease mechanism is characterized by the main evil, and the disease is rapid and changeable, with poor prognosis. ② weakness of the limbs, depression, or palpitations and palpitations, chest suffocation and panting, especially when moving, sleeplessness and good fright, or even fainting and convulsions unconsciousness. (3) Atrophy or darkness of the face, smell of urine in the mouth, light tongue with greasy coating, floating and large pulse or stringiness to the extreme.
It should be pointed out that staging is a macroscopic division of disease stages, which is different from the specific division of evidence types and should not be confused with each other. However, the stages are not fixed, and the stages can be divided but not fixed. The stage of deficiency can progress to the stage of guangs, and the stage of guangs can turn into the stage of deficiency after remission by treatment. Through the verification of nearly 30 years of clinical practice, the author believes that the staging of guango disease is feasible and has certain superiority. Its clinical guidance significance lies in: (1) the understanding of the pathogenesis, clinical features and the law of development and change has a holistic concept, and thus has a holistic guidance on the treatment; (2) it is conducive to the standardized research of the identification and treatment of guango disease and the optimization of the treatment plan; (3) it is conducive to the judgment of the prognosis.
IV. Staging and treatment
The author’s approach to the treatment of Guanger’s disease is to first identify the stage of the disease, then identify the evidence, organically combine the identification of the stage of the disease with the identification of the evidence, and then select the corresponding treatment methods and prescriptions.
(I) Deficiency stage
The clinical manifestation of patients in the deficiency stage is characterized by the symptoms of deficiency of positive qi, and the characteristics of the disease mechanism are mainly based on the deficiency of positive qi, although there are various types of Chinese medical evidence, however, the evidence of deficiency of both qi and yin is the most common.
Slowing down is treating the root of the problem and supporting the positive qi. The Su Wen? The general commentary on deficiency and reality says: “the seizure of essence is deficiency”, patients with kidney disease, prolonged illness, more deficiency, and chronic kidney failure, the degree of deficiency is bound to be more serious. At this time, we should identify the deficiency of qi, blood, yin and yang, and use the corresponding method of benefitting qi, nourishing blood, nourishing yin and warming yang. In other words, we should seek the root of the disease and support the righteousness of Qi, so that Qi, Blood, Yin and Yang can be brought into balance.
Lung Spleen Qi Deficiency]
1. Main symptoms: fatigue, sweating and cold, low voice, dullness and loose stools, pale mouth without thirst, light fat tongue with teeth marks on the edge, thin white and moist coating, sunken and weak pulse.
2.Treatment: Tonify the lung and spleen qi.
3. Remedies: (1) Tonifying Zhong Yi Qi Tang (Treatise on the Spleen and Stomach); (2) Ginseng Ling Bai Zhu San (Taiping Huimin and Pharmaceutical Bureau Formula).
Liver and Kidney Yin Deficiency
1. Main symptoms: dizziness and tinnitus, irritability, dry eyes, heat in the heart of the hands and feet, dry throat and mouth, soreness and weakness of the waist and knees, dry and yellow urine, constriction of the hands and feet or even convulsions, pale or reddish tongue, little dry or thin yellow fur, thin and counted pulse.
2. Treatment: Nourish the liver and kidney, calm the liver and submerge the yang.
3. Prescriptions: ① Qi Ju Di Huang Tang (Medical Class); ② Ma Ju Di Huang Tang (Self-designed formula); ③ Gui Shao Di Huang Tang (Self-designed formula).
Spleen and kidney Yang deficiency]
1. Main symptoms: lack of warmth in the hands and feet or coldness in the extremities, dullness and loose stools, edema of the extremities, pale mouth without thirst, cold pain in the waist and knees, nocturnal urination with clear color, withered white face, pale fat tongue with teeth marks on the edges, thin white fur and slippery water, sunken weak pulse or sluggish and feeble pulse.
2. Treatment: warming the spleen and kidney.
3.Formulas: ① Bao Yuan Tang (Bo Ai Xin Jian); ② Zhen Wu Tang (Treatise on Typhoid).
Qi and Yin deficiency]
This type of evidence is most common in the deficiency phase of chronic kidney failure, and the main point of identification is the coexistence of qi deficiency and yin deficiency. It can be divided into heart and kidney Qi-Yin deficiency, lung and kidney Qi-Yin deficiency, spleen and kidney Qi-Yin deficiency, kidney Qi-Yin deficiency, and liver and kidney Qi-Yin deficiency. The degree of Qi-Yin deficiency can be subdivided into Qi-Yin deficiency on the side of Qi deficiency, Qi-Yin deficiency on the side of Yin deficiency, and Qi-Yin deficiency on the side of both. Therefore, according to the actual situation of the patient in the clinic, the appropriate treatment should be given in order to achieve better results.
1. Main symptoms: fatigue, palpitation, shortness of breath, dizziness and tinnitus, soreness and pain in the waist and knees, spontaneous sweating or night sweating, lack of warmth in the hands and feet or heat in the heart of the hands and feet, dry throat, loose or dry stools, withered face, pale tongue with teeth marks, greasy moss or little moss and dryness, floating and large pulse or sinking and fine count and weakness.
2, Treatment: Benefit Qi and nourish Yin.
3, prescription: Ginseng and Astragalus Dihuang Tang (“Shen’s Zun Sheng Book”).
If the deficiency is on the side of qi deficiency, use dang ginseng and prince’s ginseng, increase the amount of raw astragalus, and add ginseng if the deficiency is heavy; if the deficiency is on the side of yin deficiency, increase the amount of raw dihuang, reduce the amount of prince’s ginseng and raw astragalus; if the deficiency of both qi and yin is heavy, add American ginseng.
If it is accompanied by palpitations and palpitations and sleeplessness, it is Qi-Yin deficiency of the heart and kidney, add Mai Dong, Wu Wei Zi and Fried Jujube Seed; if it is accompanied by spontaneous sweating, easy to catch cold and short of breath, it is Qi-Yin deficiency of the lung and kidney, increase the amount of raw Astragalus, change Shan Yao with Atractylodes and add Fang Feng; if it is accompanied by dullness and loose stools, it is Qi-Yin deficiency of the spleen and kidney, change Shan Yao with Atractylodes and add Chicken Nei Jin and Sha Ren; if it is accompanied by dizziness of the head and irritability, it is Qi-Yin deficiency of the liver and kidney, add Bai Shao, Tian Ma and Hang If there is dry stool, add rhubarb; if the tongue is dark or there is petechiae, add salvia.
(2) Guange stage
The clinical manifestations of the patient have the typical characteristics of Guange disease of lower Guange and upper Guange, and the pathogenesis is characterized by dampness and damp-heat obstruction. The author experienced that for the upper frame, the method of regulating the spleen and stomach is reliable and can often be turned into peace, while the treatment of the lower gate does have some difficulty.
Cold and dampness in the blockage]
1, the main symptoms: nausea and vomiting, loss of appetite, taste of urine in the mouth, no thirst in the mouth, loose and weak stool, lack of warmth in the hands and feet, withered or dark face, light fat and moist tongue, white greasy moss, floating and weak pulse or sinking and weak.
2. Treatment: Strengthening the spleen and benefiting Qi to regulate the spleen and stomach.
3.Pharmacology: Xiang Sha Liu Jun Zi Tang (“Times Square Ge Zuo”).
Dampness and heat obstruction
1. Main symptoms: nausea and vomiting, loss of appetite, heavy taste of urine in the mouth, bitterness and thirst or sticky mouth, fatigue, constipation or sticky and unpleasant stools, withered or dull complexion, pale or red tongue, yellow and greasy moss, slippery pulse.
2.Treatment: Clearing damp-heat to regulate the spleen and stomach.
3. Remedies: ① Huanglian Wenzhi Tang (Six Causes and Discernments); ② Su Ye Huanglian Tang (Warming Heat Jing Wei); ③ Han Xia Di Xie Xin Tang (Treatise on Typhoid).
Dampness and turbidity overwhelming the heart and lungs]
1. Main symptoms: chest tightness and breath-holding, chest pain, shortness of breath, inability to lie down, weakness and vomiting, oligohydramnios, pale tongue with teeth marks on the edges, thin white and watery or white greasy coating, weak or stringent and feeble pulse. It is seen in patients with uremic pericarditis.
2. Treatment: Warming Yang, remitting drinks and lowering turbidity.
3.Formulas: Shengwai yang, Ling Gui Jie Gan Tang, Dabao Dazao Diarrhea Lung Soup, Xiao Han Xia Tang (Combined formula in “Discernment of Internal and External Injuries”, “Treatise on Typhoid”, “Jin Kui Yao”).
V. Experiences
1. The advantage of Chinese medicine in the treatment of chronic renal failure lies in improving the body’s self-regulatory ability.
”Yin and Yang are dense, and the spirit is healed”, and “be careful to check where the Yin and Yang are and adjust them, in order to calm the period”. This means that adjusting the balance of yin and yang is the ultimate rule of Chinese medicine treatment. For chronic renal failure, which is characterized by deficiency of the root and the symptoms of the disease, Chinese medicine intervention is mainly based on the method of identification and treatment, with the aim of improving the patient’s self-regulation ability and actively inducing the body to enter into a benign anti-disease program, so as to alleviate the state of the upper frame of the lower gate and enable the body to reach a new homeostatic balance. As a result, the patient’s symptoms are reduced or eliminated, the quality of life is improved, and the indicators related to kidney function are significantly improved. As stated in “Typhoid Quality Difficulties”, “The key to treating a disease is to observe the body’s qi first. …… doctor to regulate the physical strength, so that it is appropriate to the natural healing energy, then the syncope can be recovered, but also the implementation of the simple way to harness the complexity.”
2, care for the right qi should be throughout.
Chinese medicine believes that “the positive does not prevail over the evil”, “the positive and the evil are growing” and the occurrence and development of disease are closely related, of which the positive qi occupies a dominant position. Guange disease deficiency period of the disease mechanism is dominated by positive deficiency, although the Guange period presents the performance of the lower Guan, upper frame, in fact, is also the result of deficiency caused by the real, and at this time the degree of deficiency of positive qi is more serious. Therefore, attention should be paid to protecting the positive energy at all times in the treatment of guanghuang disease. During the period of deficiency, corresponding tonics should be prescribed according to the location, nature and degree of deficiency. In the stage of Guange, the focus should be on saving the spleen and stomach, and protecting the qi of the spleen and stomach in order to turn danger into peace, as in Suwen? The Six Sections of the Organism, “The five flavors are hidden in the intestines and stomach, and the flavors are hidden to nourish the five qi, and the qi is in harmony with the body, and the fluids are in harmony with the body, and the gods are born.”
3. Actively prevent and control external sensations to control aggravating factors.
Chinese medicine places great emphasis on “treating the disease before it happens”, as in the Suwen? The “yin and yang should be like the great theory” said: “so the evil wind to, as the wind and rain, so good treatment of the treatment of skin and hair”. Chronic renal failure patients are prone to catching colds due to low immunity, which can aggravate or worsen the condition of renal failure, therefore, it is very important to use Chinese medicine to actively prevent and control external influenza.
The author often takes into account the prevention of colds when treating patients with deficiency, for example, patients who have spontaneous sweating and bad wind and are prone to colds, often include Yu Ping Feng San in the formula. For example, if the patient has spontaneous sweating and bad wind, and is prone to catch a cold, I often add Yu Ping Feng San to the formula. If the stool is often dry, rhubarb is added to the formula. All of the above measures can help to reduce the number of colds by preventing them before they occur.
Once the patient has a cold, the doctor should not abandon Chinese medicine and use antibacterial agents. Because Chinese medicine is a strong point in the treatment of external influenza, its strength lies in its ability to identify and treat the individual and the differences in treatment methods, such as pungent-warm, pungent-cool, and helping to relieve the symptoms. In addition, for the long summer dampness and autumn dryness, there are also methods to resolve the dampness and moisten the dryness. If the identification and selection of medicine is proper, it can often be as effective as a rafter, so as to quickly control the aggravating factors.
4. Cultivating the successive heavens to treat renal anemia.
Renal anemia has mild, moderate and severe degrees, and erythropoietin does have certain efficacy, but long-term use causes certain economic pressure to patients and has dependence. For mild and moderate anemia, the author focuses on nourishing the successive heavens and theories of Chinese medicine such as “essence and blood are of the same origin”, “blood is produced by vigorous qi” and “spleen is the source of blood production”. It was observed that when the kidney function improved and the symptoms were reduced, the anemia also improved to different degrees, and then the dosage of erythropoietin could be gradually reduced.
For patients in the deficiency stage of this disease, Ginseng-Qi Dihuang Tang is often chosen as the treatment. Among them, Liu Wei Di Huang Tang focuses on nourishing Yin and tonifying the kidney, which can have the function of filling the innate essence and blood. In the formula, ginseng and astragalus are used to benefit qi to promote blood. In severe cases, the author uses American ginseng or ginseng to supplement the power of qi. As Li Dongyuan said, “Zhongjing to ginseng for the blood, cover the blood is not self-generated, must have the drug to produce Yang Qi is born, Yang Sheng is Yin long, blood is prosperous. If yin deficiency simply tonic blood, blood is not born, there is no yang reason.”
For patients with this disease in the Guange stage, Xiang Sha Liu Jun Zi Tang or Huang Lian Wen Biao Tang are often chosen to be used to improve renal anemia by rescuing the spleen and stomach, so that the source of qi and blood can be succeeded. Regarding the choice of blood tonic, raw earth, angelica, longan meat, wolfberry and jujube are appropriate, while blood tonic drugs that are yin and soft and hinder the stomach should be used with caution.
The author believes that although the speed of raising hemoglobin is not as fast as that of erythropoietin, it is based on the mobilization of the body’s own blood-generating function, and its effect is long-lasting, without side effects and more economical.
5, careful use of blood circulation and blood stasis drugs.
Modern medical research has confirmed that the kidneys of patients with chronic renal failure are more glomerulosclerosis and interstitial fibrosis, resulting in the performance of renal atrophy. Some scholars from traditional Chinese medicine “long term illness into the complex” to start with, very much emphasis on blood circulation and treatment of blood stasis. On the contrary, the damage to the hematopoietic system caused by uremic toxins leads to platelet dysfunction and capillary brittleness, which can easily lead to bleeding tendency, and if the main treatment is to activate blood circulation and remove blood stasis, it will aggravate the bleeding situation. However, if a patient with renal failure has a dull face, blue lips and nails, tingling pain in the lower back and abdomen with fixed location, petechiae on the tongue and astringent pulse, then on the basis of identifying the evidence and selecting the prescription, we should add more peaceful blood activating drugs such as Salvia miltiorrhiza, Radix Angelicae Sinensis and Radix Achyranthes bidentata, so that the blood stasis will be removed and the righteousness will not be injured.