基于“上下交损，当治其中”探讨心血管–肾脏–代谢综合征的病机与辨治

Exploring the Pathogenesis and Syndrome Differentiation-Based Treatment of Cardiovascular-Kidney-Metabolic Syndrome Based on “When Both the Upper and Lower Are Affected, Treatment Should Target the Middle”

摘要: 心血管–肾脏–代谢综合征(CKM)是一种多系统交互紊乱的复合疾病，旨在描述肥胖、糖尿病、慢性肾脏病与心血管疾病之间的生理病理相互作用，早期以代谢紊乱为主，后期进展为心肾损伤及多器官功能紊乱。“上下交损，当治其中”出自叶天士《临证指南》，核心为上下脏腑受损，病变累及整体，治疗当以调理中焦脾胃为关键。本文基于“上下交损，当治其中”理论，结合心血管–肾脏–代谢综合征“心肾同病、代谢失序”的病理特征，认为其病机演变以脾胃失运、气机失调为病发之始，以痰瘀互结、心肾受累为病进之渐，以中焦衰败、心肾俱损为病重之势。治疗上，主张从中焦脾胃论治，遵循澄源、截流、固本三步治法，分期为中医药临床辨治心血管–肾脏–代谢综合征提供一定的理论依据与实践参考。

Abstract: The Cardiovascular-Renal-Metabolic Syndrome is a complex disorder characterized by multisystem dysregulation, aimed at describing the physiopathological interactions among obesity, diabetes mellitus, chronic kidney disease, and cardiovascular diseases; in its early stages, the condition is primarily marked by metabolic disturbances, whereas in advanced stages, it progresses to cardiac and renal impairment as well as multi-organ dysfunction. The principle “When both upper and lower systems are affected, treatment should target the middle system” is derived from Ye Tianshi’s Clinical Practice Guide; its core idea is that when the upper and lower visceral systems are compromised, the pathological changes affect the entire body, and treatment should focus on regulating the spleen and stomach in the middle jiao. Based on this principle and considering the pathological characteristics of the Cardiovascular-Renal-Metabolic Syndrome—namely the co-occurrence of cardiac and renal pathologies alongside metabolic dysregulation—this article posits that its pathogenesis begins with impaired spleen-stomach function and disrupted qi movement, progresses through the interplay of phlegm and blood stasis along with the involvement of the heart and kidneys, and culminates in the decline of the middle jiao coupled with simultaneous impairment of the heart and kidneys. In terms of treatment, this approach advocates addressing the condition through interventions targeting the spleen and stomach in the middle jiao, adhering to a three-step therapeutic strategy—clarifying the root cause, intercepting pathological flow, and reinforcing the fundamental constitution. This framework provides a theoretical basis and practical reference for the clinical differentiation and treatment of the Cardiovascular-Renal-Metabolic Syndrome using traditional Chinese medicine across different disease stages.