补肾健脾法在内科疾病中的临床应用
作者：mac 来源：文阅期刊网 日期：2021-09-02 14:31人气：
摘 要：中医理论论述的肾为先天之本，脾胃为后天之本，是贯穿中医临床治疗全过程的基本原则，其主体思想是追本溯源，标本兼顾。因此，在诸多疾病的发生发展过程中，调补脾肾尤为重要，而对于调补脾肾的治则需根据病证的不同采用不同的治疗方法，包括扶土抑木、固本培元等。补益脾肾疗法在当代常见病、高发病中应用非常常见，尤其在内科疾病的治疗中尤为突出。文章整理总结了近5年以来补肾健脾法的理论探讨与临床应用，以探求其研究进展。
关键词：补肾健脾 临床应用 研究进展
Clinical application of the method of invigorating the kidney and strengthening the spleen in internal diseases
LIU Zhichao WANG Zhenxing GAO Shengwei WANG Baohe
Tianjin University of Traditional Chinese Medicine; Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine;
Abstract：In Chinese medicine theory,the kidney is the innate basis,the spleen and stomach is the future day's life,which is the basic principle of clinical treatment throughout Chinese medicine. Its mainly idea is to trace the origin,specimen sconsideration. Therefore,in the development of many diseases,the treatment of the spleen and kidney spleen is particularly important,and the treatment of the spleen and kidney spleen needs to be different according to the different treatment methods,including soil-supporting wood,solid-ben Peiyuan and so on. In clinical,the spleen and kidneys are very common in the treatment of many modern high morbidity,and are commonly used in the treatment of internal medicine,surgery,gynecology,pediatrics,especially in the treatment of internal diseases. In this paper,the theoretical discussion and clinical application of renal spleen method have been collated for nearly 5 years in order to explore the progress of its research.
Keyword：invigorating the kidney and strengthening the spleen; clinical application; research progress;
全球范围内，约40%的糖尿病患者出现肾脏并发症，而大多数患者在进行肾脏替代治疗之前死于心血管疾病和感染[1]。目前常见的治疗方法对糖尿病患者肾脏疾病的发生和进展仍有很大的残余风险[2]，因此，围绕糖尿病肾病患者的治疗方法尚需进一步探究。补肾健脾法是中医临床诊疗中常见的补益疗法，包含兼顾先后天之本、五脏生克制化，以及异病同治等中医诊疗特色，与西医推崇的“精准医疗”不谋而合[3-4]。临床病证往往复杂多变，若久病体虚复感外邪者，滋补脾肾，真元充足，御外邪而固本；若邪实而体虚，兼以攻伐之药，亦应补脾顾肾以扶正。所以，通过补肾健脾法提高机体正气，增强抗邪能力，对疾病进程起到干预和延缓作用，对疾病的预后与转归有积极意义。本文以补肾健脾法为纲，从对补肾健脾法的认知、补肾健脾法的临床应用以及补肾健脾法的意义进行论述。
1 脾、肾在中医理论中的认识
《黄帝内经》中就有关于脾肾的解剖定位、生理功能的记载，且在后世医家著作中，又有许多关于脾肾的论述，如《脾胃论》等。综合历代研究与认识，不难发现：第一，脾主运化、升清与统血，与胃相表里，脾胃合一，因而称脾胃为后天之本[5]，假使脾胃虚弱则血气尽、腠理开，从而罹患百病，所以在治疗各系统疾病中顾护胃气是历来医家公认的中医治则。肾藏精，助气化，精足则天癸盛、骨得坚；气化则阴阳调、气血行。肾亦主水纳气，蕴真阴真阳，决定着人体先天禀赋及脏腑功能盛衰[6-7]。第二，脾肾与其他脏腑有着极其紧密的联系。明代张景岳有言：“人始生，本乎精血之源，人之既生，由乎水谷之养。”肾禀两神相搏之精，脾蕴气血生化之源，故而，肾立形体之基，脾成形体之壮，脾肾两脏可谓人之本源。张仲景在《金匮要略》中亦明确指出“五脏元真通畅，人即安和”，而五脏元真非肾精不得生，无胃气不能滋。如脾肾不足，则精不得养，谷不得化，必伤及他脏，以致心神失养，肝血失滋，肺津失润；若他脏受伤，日久必累脾肾，以致运化无权，真元失固，预后不良。同时，脾肾与其他脏腑之间在五行上存在着水火既济、金水相生、木得土达等密不可分的关系，故而在病理上也相互影响，临床一些脏腑疾病在终末期常会导致胃气衰败，甚至发生肾中阴阳离绝，因此在《伤寒论》中常有“除中”“戴阳证”等论述，在治疗上采用滋水涵木、泻南补北、益火补土、培土生金等治则，临床用药或用交泰丸交通心肾，或用一贯煎滋水涵木，或用附子理中丸益肾阳、补脾土，均体现了从脾胃论治的治法。李杲以甘温除热法为代表的补中益气汤也为从脾肾论治特殊疾病提供了思路。
2 临床应用
2.1 肾系疾病
糖尿病发病率逐年升高，已成为临床重点关注疾病。国医大师邹燕勤教授认为糖尿病肾病的核心病机是脾肾亏虚为本，湿瘀阻络为标，强调糖尿病肾病发生、发展与脾肾关系最为密切[8]。李艳玲等[9]认为脾系病变是引发糖尿病肾病的关键因素，肾脏为主要原因，其病机演变遵循“阴虚→气阴两虚→阴阳两虚”的规律。通过调补脾肾治疗糖尿病肾病的临床研究众多，胡经航等[10]利用补肾健脾通络方治疗脾肾气虚夹血瘀型Ⅲ期糖尿病肾病患者，发现补肾健脾通络方能够显著改善其血糖水平，延缓糖尿病慢性并发症的产生、发展，增强机体的特异性和非特异性免疫机能。梁敏等[11]临床研究发现健脾益肾养阴方能够有效改善终末期糖尿病肾病血液透析患者的细胞免疫功能。樊晓明[12]、宋慧丽等[13]通过脾肾双补法、健脾固肾化瘀法治疗糖尿病肾病患者，发现其能够明显改善患者的临床症状，且不良反应发生率较西药对照组低。健脾固肾活血汤联合厄贝沙坦能够改善患者肾功能，提高肾脏血流供应，降低尿蛋白，修复血管内皮损伤，可显著抑制糖尿病肾病进展[14-15]。临床大量研究表明加减真武汤、真武通脉汤等治疗脾肾阳虚型糖尿病肾病，可降低患者血糖和尿蛋白含量，减少糖尿病肾病患者危险因素，提高糖尿病肾病患者生活质量并改善肾功能，其作用机制可能是下调转化生长因子-β（TGF-β）及升高谷胱甘肽过氧化物酶（GSH-Px）等细胞因子有关[16-19]。大量临床观察[20-25]表明金匮肾气丸、济生肾气丸、参芪地黄汤等复方制剂治疗脾肾阳虚型糖尿病肾病能够改善患者临床症状和肾功能，且无严重不良反应，值得临床推广应用。综上所述，糖尿病肾病病机总属本虚标实，尤以脾肾亏虚为关键，而又兼湿、瘀，故以健脾益肾为法，由此气血调畅，湿瘀得化。
2.2 心系疾病
心系疾病包含心悸、胸痹、真心痛等中医疾病，可归属西医冠心病、心力衰竭范畴。国医大师阮士怡教授崇尚“治病必求于本”，认为冠心病辨证当从中医脾肾虚损立论，固护正气，扶正治本[26]。王林[27]通过以温肾健脾法立方的通脉方对冠心病稳定型心绞痛患者进行治疗，发现患者在心绞痛疗效、中医证候疗效及心电图疗效等方面有所改善，证实了温肾健脾活血通脉法在治疗稳定型心绞痛中的积极作用。贾红娥等[28]、马立[29]通过临床观察温肾健脾方实脾散（饮）加减配合西药治疗脾肾阳虚型慢性心力衰竭，发现该方能够改善慢性心力衰竭患者临床症状，提高生活质量。赵金龙等[30]临床研究加味真武汤治疗心力衰竭，发现其能够明显改善充血性心力衰竭心脾肾阳虚水泛兼血瘀证患者的症状积分，降低患者C反应蛋白（CRP）水平，改善心功能。由此可见，冠心病和心力衰竭等心系疾病，虽病位在心，但与脾肾密切相关，脾健能养血，肾强可养心，故而提示临床治心不忘益脾肾。
2.3 脾胃疾病
肠易激综合征是消化科常见病，归属中医泄泻范畴，其发生发展与脾肾密切相关，脾胃损伤与肾阳不足引起温养固涩失调而发为泄泻，临床中以健脾温肾立法，效果令人满意。侯建媛[31]通过临床研究发现附子理中汤合四神丸治疗脾肾阳虚型腹泻型肠易激综合征患者，可有效缓解症状。吴溪玮等[32]以现代文献研究为基础，对健脾温肾法治疗脾肾阳虚型腹泻型肠易激综合征的疗效和安全性进行系统评价，结果显示中医药健脾温肾法在疗效方面具有明显优势。胃癌是临床消化系统高危病之一，中医认为脾肾虚损是胃癌发病的基础[33]，患者中、末期生活质量不高，易形成气血阴阳亏虚，因此治疗上可予补脾益肾。刘声等[34]采用补益脾肾之扶正防癌方联合替吉奥胶囊治疗脾肾两虚型晚期胃癌患者，结果提示扶正防癌方有助于改善患者临床症状，提高其生活质量，并在一定程度上减轻化疗药物产生的不良反应。
2.4 呼吸系统疾病
慢性阻塞性肺疾病（COPD）是呼吸科常见病种，其中医病机多属肺、脾、肾俱虚，及痰、湿、瘀滞[35-37]，临床研究发现给予COPD患者温补脾肾法治疗在改善肺功能指标、运动耐力、生活质量等方面有显著疗效[38-39]。王秀萍等[40]观察健脾补肾方治疗COPD，结果表明健脾补肾方可有效改善COPD患者的临床症状及肺功能。安书芬[41]率先采用循环肿瘤细胞（CTC）评估和证候学检测方法治疗脾肾两虚型晚期小细胞型肺癌，结果提示通过健脾益肾、扶正抗瘤能够降低其CTC数量，减轻化疗毒副作用。唐建清等[42]通过自拟脾肾方治疗非小细胞肺癌在减轻消化道反应、改善骨髓抑制方面具有很好的成效。《景岳全书》云：“肺为气之主，肾为气之根。”且脾为生气之源，肺、脾、肾是决定呼吸系统健康与否的关键。COPD及小细胞型肺癌皆为肺系常见慢性疾病，病位在肺，日久连累脾肾，治疗应以补益脾肾气阴为主，兼以祛痰活血，可取得确切疗效。
2.5内分泌系统疾病
甲状腺功能减低，常表现畏寒、疲倦、嗜睡、女性月经紊乱及不孕等，中医辨证常归于阳虚。临床通过调理脾肾治疗甲状腺功能减低研究甚多，李淑彦教授常采用右归丸合理中汤加减温肾健脾药物治疗本病，取得较好疗效[43]。同时，大量临床研究证实，补脾温肾能够显著改善脾肾阳虚型甲状腺功能减低患者的中医症状，提高甲状腺功能[44-50]。甲状腺功能减低患者多肾阳不足，可见形寒肢冷，且不能温煦脾阳，以致脾阳亦虚，肌肉失养，故见肌肉无力或疼痛。脾失统血，肾气化失司而见女性月经紊乱。因此，对于甲状腺功能减低患者的诊治尤应注意固护脾阳，补益肾阳。
3 补肾健脾法的现代研究实况
“中兴思想”主张通过温补脾肾匡复元气，以预防早衰，改善健康状况[51]。此观点与西医消化系统和造血系统存在内在关联的认识一致。近几十年国内学者从整体到分子水平对肾虚的本质进行了探讨，肾的功能涵盖了西医的神经内分泌免疫网络，补肾填精药能够促进干细胞增殖，具有延缓衰老的作用[52]。现代药理研究表明，健脾类中药善于调节胃肠系统、免疫系统及泌尿系统，具有抗炎镇痛、调节脂代谢、抗血小板免疫调节等多种药理作用[53]。
4 讨论与不足
综上所述，补肾健脾法确实能够在临床上取得相应治疗效果，治疗范围囊括大部分内科疾病，其相应中医理论基础从理、法、方等方面渐臻完善，临床意义极高，相应的临床研究也能够佐证其对于临床的指导。《糖尿病肾病中医防治指南》[54]指出，糖尿病肾病已成为导致终末期肾病的首要致病因素，同时提出了中医诊疗原则，即对于糖尿病肾病早期应通过严格控制血糖、血压，可有效阻止病情进展。一旦发生临床期糖尿病肾病，肾功能呈持续性减退，直至发展为终末期肾功能衰竭，只能执行终末期肾功能衰竭的肾脏替代治疗。因此，阻断肾功能的衰退进程，从患者自身先天、后天影响因素出发，恰当运用补肾健脾法，做到未病先防的精准医疗是糖尿病肾病诊疗的首选策略。而迄今为止对糖尿病肾病的中医临床研究，多为与脾肾相关的基础研究和理论探讨，并未有确切客观的真实世界依据及循证医学考证，或是研究者对单一脏腑的研究较多，对脏腑之间相关性的研究探讨较少，这些方面有待日后逐渐完善。此外，目前对脾肾相关理论及实验研究仍然停留在初始阶段，虽然在临床应用上能够取得实际疗效，但无法达成国际共识，中医诊疗指南未得到及时更新与归纳，想要真正将中医诊疗精华推向医学前沿，不仅要进行严谨的临床研究，还要与西医紧密结合，从微观世界深入研究，解析中医理论体系的微观本质和科学内涵，才能更具有信服力。期望在下阶段的研究中，从病理生理学、临床药理学等角度更加深入地探究补肾健脾法的意义，完善现代理论研究，及时全面地更新中医诊疗指南，为临床应用提供更加有力的证据。
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