利水渗湿法治疗慢性心力衰竭伴利尿剂抵抗的研究进展

Research Progress of Water-Draining and Dampness-Percolating Method in Treating Chronic Heart Failure Complicated with Diuretic Resistance

摘要: 慢性心力衰竭(CHF)中晚期常继发利尿剂抵抗(DR)，导致容量负荷难以控制，再住院率与病死率居高不下。现代医学应对DR的策略存在电解质紊乱、肾损伤等局限。中医学将本病归于“心水”“水肿”，核心病机为本虚标实——心气、心阳亏虚为本，水湿壅滞为标，水湿停聚是诱发DR的关键环节。利水渗湿法以甘淡平和之品疏导三焦、分消水饮，临证常配伍益气、温阳、活血之品以标本兼顾。基础与临床研究证实，茯苓、泽泻、猪苓及五苓散、真武汤、猪苓汤等代表方剂，可通过调控水通道蛋白、抑制RAAS及交感激活、改善肾灌注、延缓肾小管重构等多靶点通路，增强利尿剂敏感性，减少袢利尿剂用量，改善心功能与生活质量。本文系统梳理CHF合并DR的西医机制、中医理论、药理研究、复方应用及外治协同证据，总结不足并展望方向，以期为中西医结合治疗DR提供参考。

Abstract: Diuretic resistance (DR) is a common complication in patients with advanced chronic heart failure (CHF), leading to refractory volume overload and contributing to high rates of rehospitalization and mortality. Current Western medical strategies for DR are limited by electrolyte disturbances and renal impairment. In traditional Chinese medicine (TCM), this condition falls under the categories of “heart water” and “edema”, with a core pathogenesis characterized by deficiency in origin and excess in manifestation—deficiency of heart qi and heart yang being the root, and water-dampness stagnation being the branch. The water-draining and dampness-percolating method, employing sweet and bland medicinals, acts to regulate the Triple Burner and eliminate retained fluid. In clinical practice, it is often combined with herbs that replenish qi, warm yang, and invigorate blood circulation to address both the root and the branch. Basic and clinical studies have confirmed that representative formulas such as Poria cocos, Alisma orientale, Polyporus umbellatus, Wuling powder, Zhenwu decoction, and Zhuling decoction can enhance diuretic sensitivity, reduce loop diuretic dosage, and improve cardiac function and quality of life through multi-target pathways, including regulation of aquaporins, inhibition of the RAAS and sympathetic activation, improvement of renal perfusion, and retardation of renal tubular remodeling. This article systematically reviews the Western medical mechanisms, TCM theories, pharmacological studies, compound applications, and adjunctive external therapies for CHF with DR, critically evaluates the limitations of existing evidence, and proposes future research directions, aiming to provide a reference for integrated TCM-Western medicine management of DR.