| Expert consensus on cardiorenal syndrome (CRS) has been published by KDIGO/ADQI (Kidney Disease:Improving Global Outcomes/Acute Dialysis Quality Initiative) in 2010, and it has clearly defined that CRS is a clinical syndrome that disorders of the heart and kidneys whereby acute or chronic dysfunction in one organ may induce acute or chronic dysfunction of the other. The CRS has been sub-classified into 5 types: Typel (acute CRS) reflects an abrupt worsening of cardiac function leading to acute kidney injury, Type2(chronic CRS) comprises chronic abnormalities in cardiac function causing progressive chronic kidney disease, Type 3(acute renocardiac syndrome) consists of an abrupt worsening of renal function causing acute cardiac dysfunction, Type4(chronic renocardiac syndrome) describes a state of chronic kidney disease contributing to decreased cardiac function, and Type5 (secondary CRS) reflects a systemic condition causing both cardiac and renal dysfunction. With the ageing populations, advances in the treatment of primary diseases such as hypertension and diabetes, and the prolongation of survival time, the cardiorenal syndrome has become a public health problem with increasing morbidity which we should put emphasison. Because the diversity and complexity of pathogenesis, studies of the TCM treatment of CRS are in the initial stage. the results of studies were inconsistent and limited, reasons for these may include the lack of clinical diagnostic criteria, large sample, different subtypes, classifications of renal function and heart function, different age groups, different primary diseases, different complications, subtypes of prognoses, incomplete experimental index and different statistical methods. Clinical investigations of a large number of cases on the "syndrome" and a quantitative study on TCM syndromes should be done to objectify the syndrome differentiation. The study was to provide an objective basis for the TCM treatment of CRS and increase the practical, scientific, advanced nature of CRS study by standardizing the TCM study of the cardiorenal syndrome. Preparing for the clinical multi-disciplinary, multi-system, large sample studies of TCM syndrome of CRS based on syndrome differentiation and establishing a more perfect system of TCM.1 ObjectiveThe study was to further the understanding between different subtypes of CRS syndromes by analyzing the distribution and transformation of its syndromes. In order to provide a theoretical basis for the TCM treatment of cardiorenal syndrome and an objective basis for the TCM treatment with its characteristics and advantages, the theory of traditional Chinese medicine should be combined with clinical medicine. In view of lacking comprehensive research on TCM syndrome differentiation and treatment of cardiorenal syndrome of different subtypes, the study will fill up the blank in the TCM research of cardiorenal syndrome.2 Methods (Clinical epidemiological method was adopted in the study.)2.1 Case Selection:patients with cardiorenal syndrome from January 2013 to June 2014 in Guang’anmen Hospital.2.2 Inclusion criteria:(1)age> 18 years. (2)meet the diagnostic criteria for CKD or AKI (3) comply with the diagnostic criteria for heart failure, NYHA heart level class 2-4, and associated with kidney failure.2.2.1 Diagnostic criterions of chronic renal failure were referenced with the guideline developed by Kidney Disease:Improving Global Outcomes (KDIGO) in 2012.2.2.2 Diagnostic criterions of acute kidney injury(AKI) were referenced with the guideline developed by Kidney Disease:Improving Global Outcomes (KDIGO) in 2012.2.2.3 Diagnosis and staging of AKI put forward by the expert consensus panel of acute kidney injury were adopted.2.2.4 Diagnostic criterions of AHF and CHF were referenced with 2012 ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure.2.2.5 New York Heart Association(NYHA) Functional Classification was adopted.2.2.6 Diagnostic criterions of cardiorenal syndrome were referenced with the Eleventh Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) in 2010.2.3 Exclusion criteria:(1)age<18years(2)patients with malignant arrhythmia and cancer (3)patients with diseases of liver and hematopoietic system.3 Statistical methodsSPSS16.0 statistical software package is adopted to establish the database. Frequency analysis, Spearman rank correlation analysis, Logistic regression analysis is used for statistical processing. TCM syndrome is using descriptive analysis and syndrome index count data frequency (composition)is adopted to improve the statistical description. Rank correlation analysis method is adopted to improve the measurement data of statistical description. At the same time, it is used to analyze TCM syndrome rule of heart kidney syndrome.4 ResultsGeneral information:one hundred and thirty-three patients were included in the study according to the diagnostic criterions, inclusion criteria and exclusion criteria. There were sixty-six males(49.6%) and sixty-seven females (50.4%); the youngest was 27 years old, the eldest was 84 years old, the average age was 57.12 years old; three of them were less than or equal to 40 years old (2.2%), forty-six of them were 41 to 60years old(34.6%), eighty-four of them were great than or equal to 60years old(63.2%). Primary disease:53 of them were kidney disease (39.85%),chronic glomerulonephritis accounts for the first of it; 41 of them were diabetic nephropathy (30.83%); 14 of them were renal vascular diseases (10.53%); 6 of them were polycystic kidney (4.51%); 2 of them were tubulointerstitial disease (1.50%); 31 of them belong to others (23.31%) (such as anaphylactoid purpura, lupus nephritis). Thus, the morbidity of cardiorenal syndrome caused by tubulointerstitial disease was lower than that of glomerular disease. Coronary heart disease accounts for first of heart disease, a total of 115 cases (86.47%); rheumatic heart disease, pulmonary heart disease and hypertensive cardiopathy were 18 cases altogether (13.53%).4.1 Characteristics of TCM Syndrome (deficiency and excess syndrome) Distribution of Cardiorenal Syndrome.4.1.1 Characteristics of Deficiency Syndrome Distribution of Cardiorenal Syndrome.Qi deficiency syndrome was the main deficiency syndrome type of cardiorenal syndrome.4.1.2 Characteristics of Excess Syndrome Distribution of Cardiorenal Syndrome.Blood stasis syndrome was the main deficiency syndrome types of cardiorenal syndrome.4.1.3 The relationship between Deficiency and Excess Syndrome of Cardiorenal Syndrome.Yang deficiency syndrome combined with excess syndrome:syndrome of dampness-heat(x2=6.141,p=0.013),syndrome of fluid retention (x2=8.204,p=0.004), both results were statistically significant. Yang deficiency syndrome occurred in patients without the syndrome of dampness-heat, while with a higher rate (75%) of the fluid retention syndrome.Yin deficiency syndrome combined with excess syndrome:syndrome of dampness turbidity (x2=5.048, p=0.025), syndrome of dampness-heat (x2=4.546, p=0.033), both results were statistically significant. Yin deficiency syndrome occurred in patients without the syndrome of dampness turbidity, while with a higher rate (75%) of the dampness-heat syndrome.Deficiency syndrome of both yin and yang combined with excess syndrome: syndrome of fluid retention (x2=3.948, p=0.047), the result was statistically significant. Fluid retention occurred in all patients with deficiency syndrome of both yin and yang.4.2 Characteristics of Syndrome Distribution of Cardiorenal Syndrome’ s SubtypesThe results of the rank test and Mann Whitney U test showed the syndrome distribution in different subtypes of cardiorenal syndrome, syndrome of qi deficiency (P=0.043<0.05), syndrome of blood stasis (P=0.038<0.05), syndrome of dampness turbidity (P=0.040<0.05), these results were statistically significant.Type 1:Syndrome of yin deficiency combined with dampness-heat (Z=-3.317, p=0.001), yin deficiency syndrome combined with phlegm-fluid retention(Z=-2.098, p=0.036), both results were statistically significant.Type 4:Syndrome of qi deficiency(Z=-2.516, p=0.012), syndrome of qi deficiency(Z=-3.456, p=0.001), deficiency syndrome of both yin and yang combined with fluid retention(Z=2.565, p=0.010), these results were statistically significant.4.3 The Correlation between TCM Syndromes (deficiency syndrome and excess syndrome) and Staging of Renal Function, Classification of Heart Function.4.3.1 The Correlation between TCM Syndromes(deficiency syndrome and excess syndrome)and Staging of Renal Function. Syndrome of qi deficiency was the chief deficiency syndromes of CKD patients, Syndrome of phlegm-fluid retention was the chief excess syndrome of CKD2. Syndrome of blood stasis was the chief excess syndrome of CKD3-5, The results of the rank test and Mann Whitney U test showed that the morbidity had increased in dampness turbidity syndrome with the progression of renal function, correlations between dampness turbidity and staging of renal function were significant (P=0.010).4.3.2 The Correlation between TCM Syndromes(deficiency syndrome and excess syndrome)and Classification of Heart FunctionSyndrome of qi deficiency was the chief deficiency syndromes of all classifications of heart function, Syndrome of blood stasis was the chief excess syndromes of all classifications of heart function. The morbidity increased in syndrome of qi deficiency, deficiency syndrome of both yin and yang and syndrome of phlegm-fluid retention with the progression of heart function, correlations between these three syndromes and classifications of heart function were significant(P=0.001).4.4 Study of Correlations between the Primary Disease and TCM Syndromes (deficiency syndrome and excess syndrome) of Renocardiac Syndrome4.4.1 Primary diseases:chronic glomerulonephritis accounted for the first of the primary kidney disease, coronary heart disease accounted for the first of the primary heart disease4.4.2 Correlations between the Primary Disease and Deficiency Syndrome of Renocardiac Syndrome. There was no significantly statistical difference of deficiency and excess syndrome between the primary diseases.4.5 Characteristics of Common Symptoms Distribution of Cardiorenal Syndrome.The study included 133 patients with cardiorenal syndrome, the clinical symptoms were various. The ten most common symptoms were:chest stuffy, shortage of qi and too lazy to speak, fatigue and lack of strength, lusterless complexion, soreness and weakness of waist and knees, edema, anorexia, palpitation, oliguria, thirst and bitter taste in mouth.4.6 CRS Syndromes Relationship with Age, GenderThe study showed no significant gender differences in the distribution of the syndrome (P>0.05). Correlation cofficient method were used for the determination of P value of age and Yin deficiency (p=0.013),less than 0.05, the P value showed a significant increase in the incidence of yin deficiency syndrome with age.4.7 Correlation Analysis between CRS Syndromes and Laboratory IndexThe correlation analysis between CRS syndromes and laboratory index showed no statistical significance between Laboratory Index and deficiency syndrome of qi, yin, yang, both yin and yang. Syndrome of qi and yin deficiency was positively correlated with ascending aorta diameter (P=0.041<0.05) and left ventricular thickness (p=0.013<0.05), syndrome of qi and yin deficiency became worse with the broadening of ascending aorta and increasing of left ventricular thickness. Syndrome of dampness turbidity and dampness-heat was negatively correlated with eGFR values (P=0.022<0.05), syndrome of dampness turbidity and dampness-heat became worse with the decreases of eGFR value. Syndrome of dampness turbidity and dampness-heat was positively correlated with Scr and Bun value, syndrome of dampness turbidity and dampness-heat became worse with the increases of Scr and Bun value. Syndrome of phlegm-fluid retention and SAPAII integral (P=0.002<0.05) were positively correlated, syndrome of phlegm-fluid retention became worse with the increased SAPSII integral. Syndrome of fluid retention and 24-UTP excretion(P=0.003<0.05) were positively correlated, syndrome of fluid retention became worse with the increased 24-h UTP excretion. Syndrome of blood stasis and BUN (P=0.020<0.05) were positively correlated, syndrome of blood stasis became worse with the increased level of BUN.5. Conclusion5.1 Qi deficiency syndrome was the main deficiency syndrome type of cardiorenal syndrome. Blood stasis syndrome was the main Excess syndrome types of cardiorenal syndrome. Yang deficiency syndrome occurred in patients without the syndrome of dampness-heat, while with a higher rate of the fluid retention syndrome. Yin deficiency syndrome occurred in patients without the syndrome of dampness turbidity, while with a higher rate of the dampness-heat. Fluid retention occurred in all patients with deficiency syndrome of both yin and yang.5.2 Preliminary results of this study showed that the syndrome of qi and yin deficiency had high incidence in deficiency syndromes of Typel and Type2. The syndrome of qi deficiency had high incidence in deficiency syndromes of Type3, Type4and Type5. Syndrome of blood stasis had high morbidity in excess syndromes of Type2, Type4 and Type5. Syndrome of yin deficiency usually combined with phlegm-fluid retention or dampness-heat in Typel. Syndrome of fluid retention usually combined with syndrome of qi deficiency, syndrome of yang deficiency or deficiency syndrome of both yin and yang in Type4.5.3 The morbidity had increased in dampness turbidity syndrome with the progression of renal function.The morbidity increased in syndrome of qi deficiency, deficiency syndrome of both yin and yang and syndrome of phlegm-fluid retention with the progression of heart function.5.4 Syndrome of phlegm-fluid retention became worse with the increased SAPSII integral. Therapeutic methods of replenishing qi, tonifying yin, activating blood,draining dampness, promoting urination and resolving phlegm were utilized according to the syndrome differentiation of cardiorenal syndrome. Methods of replenishing qi, clearing heat and draining dampness, activating blood, draining dampness were emphasized on CKD patients when combined with laboratory index. Pay attention to the application of resolving phlegm method for Patients who are critically ill. |
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