| Idiopathic membranous nephropathy (IMN) is one of the most common primary glomerular diseases in China and the most common cause for nephrotic syndrome in adults. The natural course of IMN is variable and a number of factors have been claimed to be able to affect the prognosis of IMN, besides, the treatment with immunosuppressive agents is not so effective. Although of all glomerular diseases, the management of membranous nephropathy has been most intensively studied, yet remains greatly controversial, which makes the clinician more confused in clinical practice. Though experts in and abroad have reached in an agreement of the treatment based on the vary degrees risk of progression, yet whether, how and when to treat IMN patients with a specific therapy is still a matter of controversy. Chinese medicine shows advantages in treating IMN,especially in reducing replase rate, relieving clinical symptoms and reducing the side effects of immunosuppressive agents. However there are still several problems which requires us to solve, such as the syndrome differentiation is quite complicated which increased the difficulty of clinical reference. My tutor, doctor zhanyongli, the chief physician, belives that we should makes the syndrome differentiation more simple and easy to follow from the theory of Qi-Blood-Water based on classic theory of Traditional Chinese Medicine. After years of clinical practice and the summary of contemporary Chinese clinicians'experience, he belives that the basic pathogenisis of IMN in Chinese medicine is qi-difficiency blood stagnation and water retention and gradually forms an initial treatment principle, that is reinforcing qi, activting blood circulation and removing water retention, which shows good effect on treating IMN. Our study is to evaluate the therapeutic effect by reviewing 55 IMN cases treated with the principle of reinforcing qi, accelerate blood circulation and removing water, meanwhile to lay the foundation for further clinal and experimental studys.Objective:To evaluate the therapeutic effect of Yiqihuoxuelishuifa in treating IMN. And a preliminarily discussion of the basic pathogenesis of IMN in TCM, that is qi-difficiency blood stagnation and water retention based on the theory of qi, blood and water in traditional Chinese medicine, meanwhile provided the theoretical basis for the treatment principle of Yiqihuoxuelishuifa on IMN.Methods:(1) Using retrospective self controlled study to analyze the therapeutic effect of 55 IMN patients as a whole group, observing pre and post scores of Chinese syndrome 24hUpro, ALB and the changes of renal function,to evaluate the general therapeutic effect. (2) The stratified analysis:Using inter-group controlled methods to compare the therapeutic effect between the group treated with Chinese medicine and those with Chinese medicine combined with immunosuppressive agents based on the same level of 24hUpro, observing pre and post scores of Chinese syndrome 24hUpro, ALB and the changes of renal function, to evaluate the general therapeutic effect.Results:(1) Therapeutic effect:analyzing 55 IMN patients as one group:①general therapeutic effect:the total effective rate is 51.5%,73.1% and 87.5% in the treatment courses of 6 months course,12 months and over 24 months. The complete remission rate is 62.5% at the group that over 24-month-treatment course, higher than reported spontaneous remission rate of 14%-56%.②Effect evaluated by score changes of Chinese syndrome:the total effective rate of is 72.7%,84.6%, and 95.8% in the treatment courses of 6 months course,12 months and over 24 months.③Effect evaluated by the change of 24hUpro:the total effective rate of is 54.5%,76.9%, and 91.7%. in the treatment courses of 6 months course,12 months and over 24 months.④The main clinical symptoms have greatly improved after treatment are edema, acratia, anorexia, spontaneous perspiration and sorness and weakness of back and knee,. Of all the patients, whose treatment course is over 12months, have better effect. More than 50% of them got toltal the clinical syndromes release.⑤The level of 24hUpro and ALB both have significant changes compareing with pre-post treatment (P<0.01).(2) The stratified analysis results:based on the level of 24hUpro:①24hUpro<3.5g cases:17 cases were treated with Chinese medicine,8 cases were treated with Chinese medicine and immunosuppressive agents. a) Effect evaluated by score changes of Chinese syndrome:the total effect rate is 94.1% and 87.5%. in the group treated with Chinese medicine and that combined with immunosuppressive agents. b) Effect evaluated by 24hUpro:the total effect rate is 88.2% and 87.5%. in the group treated with Chinese medicine and that combined with immunosuppressive agents.②24hUpro in the range of 3.5-6g:8cases were treated with Chinese medicine,14 cases were treated with Chinese medicine and immunosuppressive agents. a) Effect evaluated by score changes of Chinese syndrome:the total effect rate is 87.5% and 85.7%. in the group treated with Chinese medicine and that combined with immunosuppressive agents. b) Effect evaluated by 24hUpro:the total effect rate is 75% and 78.6% in the group treated with Chinese medicine and that combined with immunosuppressive agents. In a word no matter 24hUpro<3.5g, or 24hUpro in the range of 3.5-6g no difference was found between the two treatment protocols (P>0.05).Conclusion:1. The basic pathogenesis of IMN in TCM is qi deficiency, blood stasis and water retention, based on the classic theory of qi blood, and water.2. It shows quite prospective effects of the treatment principle of Yiqihuoxuelishui on IMN. The longer treatment courses we gave the patients, the better therapeutic effect and higher complete remission rate they got. In the short courses there shows better effect in improving clinical symptoms and in increasing ALB.3. There was no difference between the group treated with Chinese medicine and those with Chinese medicine combined with immunosuppressive agents, among the patients whose 24hUpro less than 6 gram. This result shows us the hints that whether we should treat the patients in low and middle risk with immunosuppressive agents, yet remains controversial. We could enlarge our cases and carry out a multi-center prospective randomized controlled clinical research, thus to provid more reliable clinical evidence in the future. |
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