肾脏的诊治进展与临证经验

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1、肾脏疾病的诊治进展与临证经验肾脏疾病的诊治进展与临证经验 China-Japan Friendship Hospital, China-Japan Friendship Hospital, Beijing, ChinaBeijing, ChinaLi PingLi Ping 肾脏疾病的新分类肾脏疾病的新分类急性肾脏损伤急性肾脏损伤（AcuteKidneyInjuries,AKI）慢性肾脏病慢性肾脏病（ChronicKidneyDisease,CKD）AKI的诊断标准的诊断标准肾功能在48小时内突然降低至少两次至少两次Scr升高绝对值升高绝对值 0.3mg/dl（26.5umol/L）Scr较前

2、升高较前升高50%持续6小时以上尿量 0.5ml/kg/h符合下列条件之一：单独应用尿量的改变作为诊断标准时，需要除外尿路梗阻或其他可导致尿量减少的原因。AKIN Organizing Committee 200520052005年年9 9月阿姆斯特丹月阿姆斯特丹AKIAKI的国际研讨会的国际研讨会AKI的的RIFLE分级分级反映预后AKI合作研讨会标准合作研讨会标准IIIIIIIncreased creatinine x0.5or 0.3mg/dlUO 0.3ml/kg/hx 24 hr or Anuria x 12 hrsUO 0.5ml/kg/hx 12 hrUO 0 .5ml/kg/h

3、x 6 hrIncreased creatinine x2Increase creatinine x3or creatinine 4mg/dlHighSensitivityHighSpecificity (Acute rise 0.5 mg/dl)20052005年年9 9月阿姆斯特丹月阿姆斯特丹AKIAKI的国际研讨会的国际研讨会反映预后AKI的改良的改良RIFLE分级分级 J Himmelfarb. Kidney International (2007) 71, 971976.AKI的的RIFLE分期与预后分期与预后20052005年年bellbell等回顾性分析等回顾性分析207207名

4、名CRRT治疗的治疗的AKI患者患者首次采用首次采用RIFLE分期评价分期评价AKI的预后的预后Bell. Nephrol Dial Transplant (2005) 20: 354360RIFL+E尿量能否界定能否界定CRRT的介入时机介入时机A Randomized Controlled study28例冠脉搭桥术后例冠脉搭桥术后AKI患者患者Early group 尿量尿量30ml/h 持续持续3h , 14 cases Late group 尿量尿量20ml/h持续持续2h, 14 cases86%14%Early groupLate group Souichi. Hemodialy

5、sis International. 2004; 8: 320-325RIFLE分期与CRRT介入时机介入时机 Chih-Chung Shiao. Critical Care. 2009, 13:R17125%27%13%Chronickidneydisease（CKD）Chronickidneydisease(CKD)isaworldwidepublic health problem with an increasingincidence and prevalence, poor outcomes,andhighcost.Outcomes of CKD include not only ki

6、dneyfailure but also complications of decreasedkidneyfunctionandcardiovasculardisease.Levey AS, et al. Ann Intern Med. 2003; 139: 137-147. NKF.AmJKidneyDis.2002;39:S1-246.KidneydamageKidney damage is defined as pathologic abnormalities ormarkersofdamage,includingabnormalitiesinbloodorurinetestsorima

7、gingstudies.Persistent proteinuria is the principal marker of kidneydamage.Analbumincreatinineratiogreaterthan30mg/gintwoofthreespoturinespecimensisusuallyconsideredabnormal.Levey AS, et al. Kidney Int. 2005; 67: 2089-2100. NKF.AmJKidneyDis.2002;39:S1-246.GFRcanbeestimatedfromcalibratedserumcreatini

8、neandestimatingequations, such as the Modification of Diet in Renal Disease (MDRD)StudyequationortheCockcroft-Gaultformula.The MDRD formula is recommended by European and Americanguidelines for estimating GFR，which has not been fully validated indifferentpopulationsandatdifferentstagesofCKDNKF. Am J

9、 Kidney Dis. 2002; 39: S1-246NKF. Am J Kidney Dis. 2002; 39: S1-246. . GFRApplicationofGFR-estimatingequationsinChinesepatientswithCKDToevaluatewhethertheMDRDequationscouldbeappliedaccuratelyto Chinese patients with CKD, GFR estimated by using MDRDequation7(7GFR),theabbreviatedMDRDequation(aGFR),and

10、theCockcroft-Gault equation (cGFR) were compared in patients withdifferentstagesofCKD.Dual plasma sampling of technetium Tc 99m-labeled diethylenetriaminepentaaceticacidplasmaclearancewasusedasthereferencestandardGFR(sGFR)forcomparisonof7GFRs,aGFRs,andcGFRsatdifferentstagesofCKD.Thestudyenrolled261p

11、atientswithCKD,including146menand115women.Allpatientswereolderthan18years.Zuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.Zuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.Comparisonof7GFRwithsGFRshowed that 7GFR correlatedsignificantlywithsGFR,buttheregressionlinewassignificantly different from t

12、heidenticallineMDRDEquation7AbbreviatedMDRDEquationC-GEquationb(95%CI)27.03(22.0032.05)27.73(22.6132.86)21.87(17.5126.24)m(95%CI)0.63(0.570.69)0.64(0.570.70)0.56(0.500.61)r0.780.770.78r20.600.590.61MeanSD(mL/min/1.73m2)69.7634.1570.7934.7959.6330.15ComparisonofEquation-EstimatedGFRsWith99mTc-DTPAPla

13、smaClearanceZuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.Zuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.PerformanceofGFR-EstimatingEquations:Bias,Precision,andAccuracyMDRDEquation7AbbreviatedMDRDEquationC-GEquationb(95%CI)18.09(11.3924.79)18.07(11.2624.87)15.62(9.6021.64)m(95%CI)0.24(0.320.1

14、5)0.22(0.300.13)0.37(0.460.29)r0.320.290.48r20.100.080.23Bias1,182.941,107.742,096.52Precision(mL/min/1.73m2)98.7791.2391.23Accuracywithin15%36.4034.1030.65Accuracywithin30%60.1558.2457.09Accuracywithin50%74.3374.3380.08TheregressionlineshowedthatMDRDequation7overestimatedGFRatlowlevelsandunderestim

15、ated GFR at near-normallevelsZuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.Zuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.PerformanceoftheAbbreviatedMDRDEquationinDifferentStagesofCKD99mTc-DTPAPlasmaClearance(mL/min/1.73m2)90aGFR(mL/min/1.73m2)26.8422.8035.6414.7659.4618.0482.0422.8199.8028.7

16、3Medianofdifference(mL/min/1.73m2)11.35*12.00*12.45*5.7514.30*Accuracywithin15%10.3416.6729.0348.2842.48Accuracywithin30%13.7933.3350.0081.0373.17Accuracywithin50%24.1440.0072.5893.1092.68NOTE.ValuesexpressedasmeanSDormedianofdifference(25%,75%percentile).* *P P0.05comparingestimatedGFRwithsGFR.0.05

17、comparingestimatedGFRwithsGFR. P P0.001comparingaccuraciesofanequationwiththoseinCKDstages4to5.0.001comparingaccuraciesofanequationwiththoseinCKDstages4to5.Zuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.Zuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.99mTc-DTPAPlasmaClearance(mL/min/1.73m2)90cG

18、FR(mL/min/1.73m2)23.9714.9731.0310.1847.2514.0267.6721.2986.3826.26Medianofdifference(mL/min/1.73m2)9.97*8.25*1.437.83*29.35*Accuracywithin15%13.7916.6748.3946.5517.07Accuracywithin30%17.2433.3377.4272.4153.66Accuracywithin50%20.6960.0094.8394.8391.46NOTE.ValuesexpressedasmeanSDormedianofdifference(

19、25%,75%percentile).*P0.05comparingestimatedGFRwithsGFR.P0.001comparingaccuraciesofanequationwiththoseinCKDstages4to5.P0.001comparingaccuraciesoftheC-GequationwiththoseoftheMDRDequations.PerformanceoftheC-GEquationinDifferentStagesofCKDZuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.Zuo L, et al. A

20、m J Kidney Dis. 2005; 45(3):463-72.MDRDequationsbasedondatafromChineseCKDpatientsThe MDRD equation 7 to estimate GFR (7GFR, ml/min per 1.73m2) = 170 Pcr-0.999 age-0.176 BUN-0.170 albumin0.318 0.762 ( if female) 1.211 ( if Chinese)Abbreviated MDRD equation to estimate GFR (aGFR, ml/min per 1.73m2) =

21、186 Pcr-1.154 age-0.203 0.742 ( if female) 1.233 ( if Chinese)WherePcrisinmg/dl,BUNisinmg/dl,albuminising/dl,andageisinyears.Maetal.JAmSocNephrol2006;17:2937PrevalenceofchronickidneydiseaseanddecreasedkidneyfunctionintheadultUSpopulation:TheprevalenceofCKDintheUSadultpopulationwas11%CKDCKDSubjects(S

22、ubjects(million)PrevalencePrevalenceStageStage(Ccr90ml/min)(Ccr90ml/min)(Ccr90ml/min)(Ccr90ml/min)StageStage(Ccr(Ccr(Ccr(Ccr：6060606089ml/min89ml/min89ml/min89ml/min) ) ) )StageStage(Ccr(Ccr(Ccr(Ccr：3030303059ml/min59ml/min59ml/min59ml/min) ) ) )19.2011%5.905.903.3%3.3%5.305.303.0%3.0%ThirdNationalH

23、ealthandNutritionExaminationSurveyStageStage(Ccr(Ccr(Ccr(Ccr：1515151529ml/min29ml/min29ml/min29ml/min) ) ) )StageStage(Ccr(Ccr(Ccr(Ccr15ml/min)15ml/min)15ml/min)15ml/min)TotalSubjectsTotalSubjects7.607.604.3%4.3%0.400.400.2%0.2%0.300.300.2%0.2%Coresh J, et al. Coresh J, et al. Am J Kidney Dis. 2003;

24、 41: 1-12.Am J Kidney Dis. 2003; 41: 1-12. Chadban SJ, et al. J Am Soc Nephrol. 2003;14(7 Suppl 2):S131-8.Chadban SJ, et al. J Am Soc Nephrol. 2003;14(7 Suppl 2):S131-8. PrevalenceofkidneydamageinAustrinianadults:AusDiabkidneystudyApproximately 16.4% have at least Approximately 16.4% have at least o

25、ne indicator of kidney damageone indicator of kidney damage9.7%9.7%Renal ImpairmentRenal ImpairmentProteinumiaProteinumia1.1%1.1%HematuriaHematuria3.7%3.7%0.1%0.1%0.3%0.3%0.6%0.6%0.8%0.8%11,247Australiansaged25yroroverGFR60ml/min/1.73m2（11.2%）Chen J, et al. Kidney Int. 2005; 68(6):2837-45Chen J, et

26、al. Kidney Int. 2005; 68(6):2837-45 TheoverallprevalenceofCKDwithGFR60mL/min/1.73m2was2.53%.Prevalenceofdecreasedkidneyfunctionin15,540Chineseadultsaged35to74yearsAgeyearsPercent(SE)Estimatedpopulation(SE)Total2.53(0.16)11,966,653(756,537)35440.71(0.12)1,295,194(228,878)45541.69(0.25)2,429,871(354,7

27、84)55643.91(0.44)3,369,606(383,422)65748.14(0.83)4,871,981(513,043)ChenJ,etal.KidneyInt.2005;68(6):2837-45.Overall,theage-standardizedprevalencesofGFR60to89,30to59,and30mL/min/1.73m2were39.4%,2.4%,and0.14%,respectively.Age-standardizedandage-specificprevalenceofdecreasedkidneyfunctionwithGFR60mL/min

28、/1.73m2estimatedusingthesimplifiedMDRDstudyequationinChineseadultsaged35to74yearsCommunity-basedscreeningforchronickidneydiseaseamongpopulationolderthan40yearsinBeijing,ChinaSubjects:2353residentsolderthan40years. Results:Results:Approximately11.3%ofsubjectshadatleastoneApproximately11.3%ofsubjectsh

29、adatleastoneindicatorofkidneydamage.indicatorofkidneydamage.(1).Albuminuria(albumin/creatinine30mg/g),6.2%;(1).Albuminuria(albumin/creatinine30mg/g),6.2%;(2).GFR60ml/min/1.73m2,5.2%;(2).GFR60ml/min/1.73m2,5.2%;(3).Hematuria,0.8%;(3).Hematuria,0.8%;(4).Non-infectivepyuria,0.09%.(4).Non-infectivepyuri

30、a,0.09%.Zhang L, et al. Zhang L, et al. Nephrol Dial Transplant. 2007; 22: 1093 Nephrol Dial Transplant. 2007; 22: 1093 Analysisbasedon13,519renalbiopsiesinChinaCasesofrenalbiopsiesperformedeachyearLi LS, Liu ZH. Kidney Int. 2004; 66(3): 920-3.Li LS, Liu ZH. Kidney Int. 2004; 66(3): 920-3. *P0.01;*P

31、3mg/dl,N=607)ChinesemaintenancedialysisuAccordingtotheregistrationofdialysisandtransplantationin China in 1999, 41775 patients underwent maintenancedialysis; among them, 89.5% was hemodialysis (HD) and10.5%wasperitonealdialysis(PD).uThefirstcauseofCRFinHDpatientswasglomerulonephritis(50%), and then

32、diabetic nephropathy (13.5%), hypertensivenephrosclerosis(8.9%).Dialysis and Transplantation Registration Group. Chin J Nephrol. 2001; 17: 77-78. Dialysis and Transplantation Registration Group. Chin J Nephrol. 2001; 17: 77-78. Annual average incidence of ESRDPrevalence of ESRDEurope135 new patients

33、 per million of population700 patients per million of populationUSA336 new patients per million of population1403 patients per million of populationAnnual incidence ofHD PDPrevalence of HD PDShanghai135 20 patientsper million of population180 34 patientsper million of populationThese data showed tha

34、t the annual incidence rate of dialysis in Shanghai, China was coincident with the annual average incidence of ESRD in Europe. However, prevalence of dialysis has marked difference between Europe and Shanghai. The financial problem may be the most important cause of the difference formation. MeguidE

35、l,etal.Lancet.2005;365:331-340.Shanghaidialysisandtransplantationregistrationgroup.ChinJNephrol.2001;17:83-85.Comparisons of incidence and prevalence of ESRD in developed countries and China1658childhoodwithCRFinChinauThecriterionofCRFwascreatinineclearance(Ccr)115umol/LUP1.0g/24hGlomerulosclerosis2

36、CrescentformationInterstitialinjury2Multivariteanalysisofinfluercingfactorsforhypertensionin540patientswithIgANZhuang Y, Chen X, et al. Zhuang Y, Chen X, et al. Chin J Intern Med. 2000; 39: 371-375. Chin J Intern Med. 2000; 39: 371-375. CharacteristicsCharacteristicsOROROR95%CIOR95%CIPvaluePvalueAge

37、AgeFamilialhistoryofHTFamilialhistoryofHTProteinuriaProteinuriaSerumcreatinineSerumcreatinineBodyweightBodyweightRenalarteriolarlesionRenalarteriolarlesion1.0481.0486.7326.7321.0181.0181.2681.2681.0291.0292.1932.1931.022-1.0741.022-1.0741.662-27.2641.662-27.2641.011-1.0251.011-1.0251.107-1.4471.107-

38、1.4471.006-1.0521.006-1.0521.637-2.9381.637-2.9380.00010.00010.00750.00750.00010.00010.00040.00040.00920.00920.00010.0001TheprevalenceofhypertensioninIgANwas39.6%(214/540)atthetimeofrenalbiopsy.Characteristicsoftubulointerstitiallesions(TIL)in609patientswithIgANDegreeandpercentofTIL:lmildTIL47.1%,lm

39、oderateTIL21.7%,lsevereTIL16.6%,lNon-TIL14.6%.RelatedfactorswithseverityofTIL:lhypertension,lthelevelofproteinuria,lthescoresofvascularlesion,ltotalglomerularlesion,lhypercellularity,lglomerulosclerosisZhang Y, Chen X, et al. Zhang Y, Chen X, et al. Chin J Intern Med. 2001; 40: 613-617. Chin J Inter

40、n Med. 2001; 40: 613-617. Prevention of CKDPrimarypreventionofCKDwillrelyoncontrollingtheobesityandassociatedtype2diabetesaswellashypertension.suchasweightreduction,exercise,anddietarymanipulations.SecondarypreventionofprogressionofCKDneedspharmacologicalapproaches.MolichM,etal.JAmSocNephrol.2003;14

41、:S103107.AppelLJ.JAmSocNephrol.2003;14:S99102.MoserM.JClinHypertens.2004;6:S413.Management of CKDCurrentmanagementoptionsforCKDarebasedonthecontrolofknownriskfactorssuchashypertension,proteinuria,hyperlipidaemia,andsmoking.Controlofhypertensionisthesinglemosteffectiveintervention.Antihypertensiveapp

42、roacheswithinhibitorsofACEorangiotensin-2-receptorblockershavebeenwidelyadvocated.Controlofproteinuriaandtheinhibitionoftherennin-angiotensinsystemareimportantfactorsinslowingtheprogressionofdiabeticandnon-diabeticCKD.RemuzziG,etal.AnnInternMed.2002;136:604615.GaedeP,etal.NEnglJMed.2003;348:383393.我

43、们所面对新的挑战我们所面对新的挑战CVDisanepidemicDiabetesisanepidemicCKDisanepidemicCVDandDMareleadingcausesofCKDCKDisariskfactorforCVDDialysisiscostlyDialysisislifesaving中西医治疗中西医治疗CKDCKD的现状分析的现状分析肾脏病的演变肾脏病的演变 肾脏病的表现肾脏病的表现 肾脏病的治疗肾脏病的治疗 治疗的局限性治疗的局限性 早期早期CKD1CKD1期期 中期中期CKD2-3CKD2-3期期 中晚期中晚期CKD4CKD4期期 尿毒症尿毒症 单纯血尿单纯血尿轻度

44、蛋白尿轻度蛋白尿合并高血压合并高血压大量蛋白尿大量蛋白尿 透析透析肾移植肾移植降压药降压药糖皮质激素糖皮质激素免疫抑制剂免疫抑制剂西医西医无特殊治疗无特殊治疗疗效有限疗效有限药副作用大药副作用大肾功能不全肾功能不全尿毒症前期尿毒症前期晚期晚期 CKD5CKD5期期 西医西医无特殊治疗无特殊治疗低蛋白饮食低蛋白饮食必需氨基酸必需氨基酸 寻找并去除寻找并去除危险因素危险因素 治标不治本治标不治本 器官来源不足器官来源不足医疗费用高医疗费用高中医治疗优势中医治疗优势 针对血尿针对血尿蛋白尿治疗蛋白尿治疗降低蛋白尿降低蛋白尿减少副作用减少副作用延缓肾脏延缓肾脏疾病进展疾病进展推迟进入透析推迟进入透析时

45、间时间, ,减少医减少医疗费用疗费用CKD中医治疗十法中医治疗十法滋养肝肾法滋养肝肾法症属肝肾阴虚者，或辨证属气阴两虚以阴症属肝肾阴虚者，或辨证属气阴两虚以阴虚为主者，方选杞菊地黄汤、归芍地黄汤、虚为主者，方选杞菊地黄汤、归芍地黄汤、一贯煎合二至丸、桑麻丸等加减。稍有乏一贯煎合二至丸、桑麻丸等加减。稍有乏力者可加太子参；有心悸怔忡者，可合用力者可加太子参；有心悸怔忡者，可合用生脉饮；失眠者加柏子仁或酸枣仁；口燥生脉饮；失眠者加柏子仁或酸枣仁；口燥咽干甚者加麦冬、五味子等；兼尿频、尿咽干甚者加麦冬、五味子等；兼尿频、尿急、尿热、尿痛者，可用知柏地黄汤加滑急、尿热、尿痛者，可用知柏地黄汤加滑石、车

46、前子等。石、车前子等。健脾益肾法健脾益肾法适用证属脾肾气虚者，方选七味白术散、参苓白适用证属脾肾气虚者，方选七味白术散、参苓白术散加菟丝子、补骨脂；兼自汗者可合用玉屏风术散加菟丝子、补骨脂；兼自汗者可合用玉屏风散；兼腰膝冷痛者加狗脊、川牛膝；兼下肢水肿散；兼腰膝冷痛者加狗脊、川牛膝；兼下肢水肿者，可合用防已地黄汤或防已茯苓汤；兼有纳少者，可合用防已地黄汤或防已茯苓汤；兼有纳少腹胀者可加砂仁、寇仁；兼心悸气促者，可合用腹胀者可加砂仁、寇仁；兼心悸气促者，可合用苓桂术甘汤等、葶苈大枣泻肺汤等。苓桂术甘汤等、葶苈大枣泻肺汤等。 益气养阴法益气养阴法方选参芪地黄汤为主，兼下肢肿加车前子、冬葵方选参芪地

47、黄汤为主，兼下肢肿加车前子、冬葵子、冬瓜皮、抽葫芦、防己；兼湿热者加白花蛇子、冬瓜皮、抽葫芦、防己；兼湿热者加白花蛇舌草、石苇、；兼瘀血者加丹参、泽兰、红花；舌草、石苇、；兼瘀血者加丹参、泽兰、红花；兼气滞者加广木香、槟榔、陈皮、大腹皮；气虚兼气滞者加广木香、槟榔、陈皮、大腹皮；气虚明显加入红参另煎兑服；阴虚明显加黄芪、石斛；明显加入红参另煎兑服；阴虚明显加黄芪、石斛；兼阳虚加仙茅、仙灵脾等；兼浊毒者加入生大黄，兼阳虚加仙茅、仙灵脾等；兼浊毒者加入生大黄，或加用大黄灌肠；有痈疽者加金银花、蒲公英、或加用大黄灌肠；有痈疽者加金银花、蒲公英、野菊花、天葵子、败酱草等；尿中有酮体加黄芩、野菊花、天葵

48、子、败酱草等；尿中有酮体加黄芩、黄连、黄柏；合并周围神经病变加当归、菊花等。黄连、黄柏；合并周围神经病变加当归、菊花等。阴阳双补法阴阳双补法适于CKD晚期阴阳两虚者，此为气阴两虚进一步发展而来。方选桂附地黄汤等。兼水湿用济生肾气汤，贫血明显者，以红参另煎兑服，浊毒盛加生大黄。 祛风散热法祛风散热法适于外感风热或风寒化热者，可用银翅散加减。阴虚者可用银翅汤，咽痛合银蒲玄麦甘桔汤（经验方，由银花、蒲公英、玄参、麦冬、桔梗、甘草等）、升降散。热毒甚者可合用五味消毒饮、黄连解毒汤。 清热利湿法清热利湿法适用于兼湿热症状者。一般在扶正基础上适用于兼湿热症状者。一般在扶正基础上加入清利之品。湿热重宜先清利

49、湿热，上加入清利之品。湿热重宜先清利湿热，上焦痰热可用贝母瓜萎散、杏仁滑石汤；中焦痰热可用贝母瓜萎散、杏仁滑石汤；中焦湿热可用八正散去木通，或五麻散、石焦湿热可用八正散去木通，或五麻散、石苇散、程氏萆解分清饮。若湿热弥漫三焦苇散、程氏萆解分清饮。若湿热弥漫三焦可用三仁汤、嵩芩清胆汤等以清热除湿，可用三仁汤、嵩芩清胆汤等以清热除湿，宣畅三焦。宣畅三焦。渗利水湿法渗利水湿法适于挟水湿者。仅下肢浮肿，可于扶正方适于挟水湿者。仅下肢浮肿，可于扶正方中加牛膝、车前子以渗利水湿。如水肿严中加牛膝、车前子以渗利水湿。如水肿严重则宜先渗利水湿，脾虚明显者可用防己重则宜先渗利水湿，脾虚明显者可用防己黄芪汤合防己

50、茯芩汤、大橘皮汤；血瘀者黄芪汤合防己茯芩汤、大橘皮汤；血瘀者可用桂枝茯芩丸、当归芍药散加减；水肿可用桂枝茯芩丸、当归芍药散加减；水肿严重者，亦可前后分消，可用己椒苈黄丸、严重者，亦可前后分消，可用己椒苈黄丸、疏凿饮子；水凌心肺可用苓桂术甘汤合葶疏凿饮子；水凌心肺可用苓桂术甘汤合葶苈大枣泻肺汤。苈大枣泻肺汤。 理气开郁法理气开郁法适于兼有气郁症状者。气郁的产生可与情适于兼有气郁症状者。气郁的产生可与情绪波动，焦虑忧郁，或水湿、湿热、瘀血绪波动，焦虑忧郁，或水湿、湿热、瘀血等因素导致气机受阻有关。可于扶正方中等因素导致气机受阻有关。可于扶正方中加入调理气机之品。气郁严重者宜先理气加入调理气机之品。

51、气郁严重者宜先理气开郁，用逍遥散、柴胡疏肝散、越鞠丸、开郁，用逍遥散、柴胡疏肝散、越鞠丸、四逆散等。水湿明显者，在渗利水湿方中四逆散等。水湿明显者，在渗利水湿方中加入陈皮、广木香、槟榔、大腹皮、沉香加入陈皮、广木香、槟榔、大腹皮、沉香等理气之品，气行水亦行，有助于水肿消等理气之品，气行水亦行，有助于水肿消退。退。活血化瘀法活血化瘀法适用于瘀血症状明显或严重者，特别是合并其它血管病变者，常选桂枝茯苓丸、血府逐瘀汤、桃仁四物汤、桃核承气汤等方加减治疗。慢性肾脏病病程较长，正气亏虚，气机逆乱，血瘀证普遍存在，迁延难愈，因此活血化瘀法较为常用，一般可在扶正基础上加入活血化瘀之品。泄浊解毒法泄浊解毒法适用于终末期，浊毒弥漫，阴阳俱虚。轻适用于终末期，浊毒弥漫，阴阳俱虚。轻者可于扶正方中加入大黄以泄浊；重则可者可于扶正方中加入大黄以泄浊；重则可配合大黄牡蛎方、大黄穿心莲方等煎汁灌配合大黄牡蛎方、大黄穿心莲方等煎汁灌肠或肛门点滴。肠或肛门点滴。 Thank you!