Efficacy of tripterygium glycosides combined with ARB on diabetic nephropathy: a meta-analysis

The mechanisms underlying Chinese medicines to treat inflammation in diabetic kidney disease

ETHNIC PHARMACOLOGICAL RELEVANCE

Diabetic kidney disease (DKD) is the main cause of end-stage renal disease (ESRD), which is a public health problem with a significant economic burden. Serious adverse effects, such as hypotension, hyperkalemia, and genitourinary infections, as well as increasing adverse cardiovascular events, limit the clinical application of available drugs. Plenty of randomized controlled trials(RCTs), meta-analysis(MAs) and systematic reviews(SRs) have demonstrated that many therapies that have been used for a long time in medical practice including Chinese patent medicines(CPMs), Chinese medicine prescriptions, and extracts are effective in alleviating DKD, but the mechanisms by which they work are still unknown. Currently, targeting inflammation is a central strategy in DKD drug development. In addition, many experimental studies have identified many Chinese medicine prescriptions, medicinal herbs and extracts that have the potential to alleviate DKD. And part of the mechanisms by which they work have been uncovered.

AIM OF THIS REVIEW

This review aims to summarize therapies that have been proven effective by RCTs, MAs and SRs, including CPMs, Chinese medicine prescriptions, and extracts. This review also focuses on the efficiency and potential targets of Chinese medicine prescriptions, medicinal herbs and extracts discovered in experimental studies in improving immune inflammation in DKD.

METHODS

We searched for relevant scientific articles in the following databases: PubMed, Google Scholar, and Web of Science. We summarized effective CPMs, Chinese medicine prescriptions, and extracts from RCTs, MAs and SRs. We elaborated the signaling pathways and molecular mechanisms by which Chinese medicine prescriptions, medicinal herbs and extracts alleviate inflammation in DKD according to different experimental studies.

RESULTS

After overviewing plenty of RCTs with the low hierarchy of evidence and MAs and SRs with strong heterogeneity, we still found that CPMs, Chinese medicine prescriptions, and extracts exerted promising protective effects against DKD. However, there is insufficient evidence to prove the safety of Chinese medicines. As for experimental studies, Experiments in vitro and in vivo jointly demonstrated the efficacy of Chinese medicines(Chinese medicine prescriptions, medicinal herbs and extracts) in DKD treatment. Chinese medicines were able to regulate signaling pathways to improve inflammation in DKD, such as toll-like receptors, NLRP3 inflammasome, Nrf2 signaling pathway, AMPK signaling pathway, MAPK signaling pathway, JAK-STAT, and AGE/RAGE.

CONCLUSION

Chinese medicines (Chinese medicine prescriptions, medicinal herbs and extracts) can improve inflammation in DKD. For drugs that are effective in RCTs, the underlying bioactive components or extracts should be identified and isolated. Attention should be given to their safety and pharmacokinetics. Acute, subacute, and subchronic toxicity studies should be designed to determine the magnitude and tolerability of side effects in humans or animals. For drugs that have been proven effective in experimental studies, RCTs should be designed to provide reliable evidence for clinical translation. In a word, Chinese medicines targeting immune inflammation in DKD are a promising direction.

lncRNA and circRNA expression profiles in the hippocampus of Aβ25‑35‑induced AD mice treated with Tripterygium glycoside

Tripterygium glycosides (TG) have been reported to ameliorate Alzheimer's disease (AD), although the mechanism involved remains to be determined. In the present study, the lncRNA and circRNA expression profiles of an AD mouse model treated with TG were assessed using microarrays. lncRNAs, mRNAs, and circRNAs in the hippocampi of 3 AD+normal saline (NS) mice and 3 AD+TG mice were detected using microarrays. The most differentially expressed lncRNAs, mRNAs, and circRNAs were screened between the AD+NS and AD+TG groups. The differentially expressed lncRNAs and circRNAs were analyzed using GO enrichment and KEGG analyses. Co-expression analysis of lncRNAs, circRNAs, and mRNAs was performed by calculating the correlation coefficients. Protein-protein interaction (PPI) network analysis was performed on mRNAs using STRING. The lncRNA-target-transcription factor (TF) network was analyzed using the Network software. In total, 661 lncRNAs, 64 circRNAs, and 503 mRNAs were found to be differentially expressed in AD mice treated with TG. Pou4f1, Egr2, Mag, and Nr4a1 were the hub genes in the PPI network. The KEGG results showed that the mRNAs that were co-expressed with lncRNAs were enriched in the TNF, PI3K-Akt, and Wnt signaling pathways. LncRNA-target-TF network analysis indicated that TFs, including Cebpa, Zic2, and Rxra, were the most likely to regulate the detected lncRNAs. The circRNA-miRNA interaction network indicated that 275 miRNAs may bind to the 64 circRNAs. In conclusion, these findings provide a novel perspective on AD pathogenesis, and the detected lncRNAs, mRNAs, and circRNAs may serve as novel therapeutic targets for the management of AD.

Chinese herbal medicine and its active compounds in attenuating renal injury via regulating autophagy in diabetic kidney disease

Diabetic kidney disease (DKD) is the main cause of end-stage renal disease worldwide, and there is a lack of effective treatment strategies. Autophagy is a highly conserved lysosomal degradation process that maintains homeostasis and energy balance by removing protein aggregates and damaged organelles. Increasing evidence suggests that dysregulated autophagy may contribute to glomerular and tubulointerstitial lesions in the kidney under diabetic conditions. Emerging studies have shown that Chinese herbal medicine and its active compounds may ameliorate diabetic kidney injury by regulating autophagy. In this review, we summarize that dysregulation or insufficiency of autophagy in renal cells, including podocytes, glomerular mesangial cells, and proximal tubular epithelial cells, is a key mechanism for the development of DKD, and focus on the protective effects of Chinese herbal medicine and its active compounds. Moreover, we systematically reviewed the mechanism of autophagy in DKD regulated by Chinese herb compound preparations, single herb and active compounds, so as to provide new drug candidates for clinical treatment of DKD. Finally, we also reviewed the candidate targets of Chinese herbal medicine regulating autophagy for DKD. Therefore, further research on Chinese herbal medicine with autophagy regulation and their targets is of great significance for the realization of new targeted therapies for DKD.

Therapeutic mechanism and clinical application of Chinese herbal medicine against diabetic kidney disease

Diabetic kidney disease (DKD) is the major complications of type 1 and 2 diabetes, and is the predominant cause of chronic kidney disease and end-stage renal disease. The treatment of DKD normally consists of controlling blood glucose and improving kidney function. The blockade of renin-angiotensin-aldosterone system and the inhibition of sodium glucose cotransporter 2 (SGLT2) have become the first-line therapy of DKD, but such treatments have been difficult to effectively block continuous kidney function decline, eventually resulting in kidney failure and cardiovascular comorbidities. The complex mechanism of DKD highlights the importance of multiple therapeutic targets in treatment. Chinese herbal medicine (active compound, extract and formula) synergistically improves metabolism regulation, suppresses oxidative stress and inflammation, inhibits mitochondrial dysfunction, and regulates gut microbiota and related metabolism via modulating GLP-receptor, SGLT2, Sirt1/AMPK, AGE/RAGE, NF-κB, Nrf2, NLRP3, PGC-1α, and PINK1/Parkin pathways. Clinical trials prove the reliable evidences for Chinese herbal medicine against DKD, but more efforts are still needed to ensure the efficacy and safety of Chinese herbal medicine. Additionally, the ideal combined therapy of Chinese herbal medicine and conventional medicine normally yields more favorable benefits on DKD treatment, laying the foundation for novel strategies to treat DKD.

Efficacy and safety of Abelmoschus moschatus capsules combined with tripterygium glycoside tablets on diabetic nephropathy: A systematic review and meta-analysis

Background: Diabetic nephropathy (DN) is one of the most serious chronic micro-vascular complications of diabetes and the leading cause of end-stage kidney disease (ESRD) worldwide, with reduced expectancy and quality of life and colossal financial and social burden worldwide. In spite of emerging treatments on DN, effective therapy on delaying the progression of DN is still lacking. In clinical practice, there are many studies focusing on Abelmoschus moschatus (AM) capsules together with Tripterygium glycoside (TG) tablets in the treatment of DN, and excellent results have been obtained.

Objective: The study aimed to evaluate the efficacy and safety of AM combined with TG in the treatment of DN.

Methods: Databases including PubMed, Web of Science, Cochrane Library, Embase, CNKI, WF, and VIP were searched from their inception to 1 March 2022. The “risk of bias” evaluation tool produced by the Cochrane Collaboration Handbook was used for evaluating the quality of the included studies. Revman 5.3 software was used for meta-analysis.

Results: Here, 11 studies with a total of 1,072 participants were included for this meta-analysis. Our results showed that AM combined with TG plus basic treatment could lower levels of 24 h-UP [MD = -0.18; 95% CI: (-0.21, -0.14); p < 0.00001], Scr [MD = -15.29; 95% CI: (-28.69, -1.88); p = 0.03], and BUN [MD = -1.18; 95% CI: (-1.69, -0.68); p < 0.00001]. Meanwhile, the adverse reaction rate increased in the combination group [RR = 1.88; 95% CI (1.26, 2.82); p = 0.002].

Conclusion: Current evidence suggests that AM combined with TG may be more effective in the treatment of DN, which will be highly beneficial to further theoretical discussion and practical clinical applications. However, the safety cannot be ignored because of nearly increasing 2-fold adverse events, although they can be mitigated through systematic treatment. Meanwhile, due to low quality of the included studies, great possibility of publication bias, and large heterogeneity among different studies, the results of our review should be evaluated with more prudence and high-quality RCTs are warranted to confirm this in the future.

Systematic review Registration:www.crd.york.ac.uk, identifier CRD42022344359.

Clinical efficacy, safety, and cost of nine Chinese patent medicines combined with ACEI/ARB in the treatment of early diabetic kidney disease: A network meta-analysis

Objectives: To evaluate and compare the efficacy, safety, and cost of nine Chinese patent medicines (CPMs) combined with angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) in treating early diabetic kidney disease (DKD).

Design: Systematic review and network meta-analysis.

Data sources: PubMed, Embase, Cochrane Library, Web of Science, clinicaltrials.gov, SinoMed, Chinese Biomedicine, China National Knowledge Infrastructure, WanFang, and Chongqing VIP Information databases were comprehensively searched from the beginning to February 2022.

Review Methods: Randomized controlled trials (RCTs) including Bailing capsule (BLC); Jinshuibao capsule (JSB); Huangkui capsule (HKC); Compound Xueshuantong capsule (CXC); uremic clearance granule (UCG); Shenyan Kangfu tablet (SYKFT); tripterygium glycosides (TG); Keluoxin capsule (KLX), and Shenshuaining tablet (SSNT) combined with ACEI/ARB for patients with early DKD were reviewed.

Data Synthesis: Two reviewers independently screened articles, extracted data, and assessed the risk of bias. Risk ratios (RRs) and mean difference (MD) were reckoned to assess dichotomous variable quantities and continuous variable quantities, respectively. Using the surface under the cumulative ranking curve (SUCRA), we then ranked each therapeutic regime.

Results: Ultimately, 160 RCTs involving 13,365 patients and nine CPMs were included. UCG showed significantly higher probabilities on urinary albumin excretion rate (UAER) when compared with ACEI/ARB group, with MD of −47 (95%CI) (−57, −37) and SUCRA 98.0%. The CXC group achieved a remarkable improvement in overall response rate (ORR) compared with ACEI/ARB (RR, 1.3, 95%CI (1.2, 1.5)) with SUCRA 91.9%. SSNT could be significantly superior to ACEI/ARB group in terms of serum creatinine (Scr) (−19 (−26, −12), SUCRA 99.3%) and adverse effects (AEs) (0.46 (0.17, 1.1), SUCRA 82.9%). BLC showed the greatest effectiveness on 24 h urinary total protein (24 h UTP) (−170 (−260, −83), SUCRA 78.5%) and triglyceride (Trig) (−0.89 (−1.2, −0.53), SUCRA 97.0%). From the cost-effectiveness analysis of CPMs in China, the cost of TG, SYKFT and CXC was 108, 600, and 648 RMB, respectively, per 3 months and were ranked in the top three.

Conclusion: UCG and CXC might be the optimum selection for improving UAER and ORR, and SSNT could be significantly superior to ACEI/ARB group in terms of Scr and AEs. BLC shows the best curative effect on 24 h UTP and Trig. TG shows the highest cost-effectiveness among the nine CPMs.

Quality of Evidence Supporting the Role of Tripterygium Glycosides for the Treatment of Diabetic Kidney Disease: An Overview of Systematic Reviews and Meta-Analyses

Background

Tripterygium glycosides (TG) is widely used in the treatment of diabetic kidney disease (DKD) in China. To systematically assess and synthesize the available evidence, we present an overview of systematic reviews (SRs) and meta-analyses (MAs) on the topic of TG interventions for DKD.

Methods

SRs/MAs on TG interventions for DKD were comprehensively searched in seven databases. Methodological quality, risk of bias, reporting quality, and quality of evidence were assessed using the Assessment of Multiple Systematic Reviews 2 (AMSTAR-2), the Risk of Bias in Systematic (ROBIS) scale, the list of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), as well as the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

Results

This overview includes 13 SRs/MAs that use quantitative calculations to comprehensively assess various outcomes in TG interventions for DKD. The methodological quality, reporting quality, and risk of bias of SRs/MAs, and the quality of evidence for outcome indicators are unsatisfactory. Limitations of the included SRs/MAs consist in the lack of essential procedures such as protocol registration, screening of duplicate study, provision of the list of excluded studies, and assessment of publication bias. Besides, the reliance on small samples for quantitative synthesis of effect sizes also constitutes an important limitation.

Conclusion

TG may be a potential complementary treatment modality to DKD therapy. However, this conclusion must be treated with caution as the quality of the evidence provided by SRs/MAs is generally low.

New Insights Into the Effects of Individual Chinese Herbal Medicines on Chronic Kidney Disease

The clinical and experimental study into the effects of Chinese herbal medicines on chronic kidney disease has evolved over the past 40 years with new insight into their mechanism and evidence of their clinical effects. Among the many traditional Chinese herbs examined in chronic renal disease, five were found to have evidence of sufficient clinical efficacy, high frequency of use, and well-studied mechanism. They are: Abelmoschus manihot and Huangkui capsule, Salvia miltiorrhiza and its components (tanshinone II A, salvianolic acid A and B); Rhizoma coptidis and its monomer berberine; Tripterygium wilfordii and its components (triptolide, tripterygium glycosides); Kudzu root Pueraria and its monomer Puerarin. These Chinese herbal medications have pharmaceutical effects against fibrosis, inflammation and oxidative stress and also promote renal repair and regeneration. This article reviews their clinical efficacy, anti-fibrotic effects in animal models, and molecular mechanism of action.

Efficacy and safety of Huangkui capsule for diabetic nephropathy: A protocol for systematic review and meta-analysis

BACKGROUND

Diabetic nephropathy (DN) is 1 of the most serious complications of diabetes mellitus and the leading cause of end-stage renal disease in the world. Huangkui capsule, extracted from Abelmoschus manihot (L.) medic (AM), has been widely used to treat DN. However, there is no consensus on the efficacy of Huangkui capsule for DN. This study aims to perform meta-analysis to systematically review the efficacy and safety of Huangkui capsule.

METHODS

The following 9 electronic databases will be comprehensively searched: PubMed, web of science, MEDLINE, Embase, Cochrane Library, China National Knowledge Infrastructure, Chinese Scientific Journals Database, Wanfang data, and Chinese BioMedicine Literature Database. The retrieval time is from their inception to May 2021. According to the inclusion and exclusion criteria, 2 reviewers independently completed the study selection, data extraction, risk of bias assessment, and data synthesis. Review Manager Version 5.3 software will be used to conduct meta-analysis.

RESULTS

This study provides a high-quality synthesis to assess the efficacy of Huangkui capsule for treating diabetic nephropathy.

CONCLUSION

The result of this systematic review will provide objective evidence-based basis to judge the effectiveness and safety of Huangkui capsule on diabetic nephropathy.

Efficacy of tripterygium glycosides for diabetic nephropathy: a meta-analysis of randomized controlled trials

Backgrounds

Diabetic nephropathy (DN) is one of the most important clinical complications of diabetes mellitus (DM) and is the most common cause of end-stage renal disease. Currently, there is no highly effective medicine that can prevent, halt, or reverse the progressive course of DN. Initial clinical data showed that Tripterygium glycosides (TGs), a traditional Chinese medicine, can decrease proteinuria in patients with DN.

Objectives

The objective of the present study is to investigate the efficacy and safety of TGs for the treatment of DN through meta-analysis of randomized controlled trials (RCTs).

Methods

All RCTs of TGs for DN were collected from The China National Knowledge Infrastructure (CNKI), PubMed, Web of Science, Wanfang Data, Chinese Biomedical Literature Database (CBM), China Science and Technology Journal Database (VIP) by setting the study inclusion and elimination standards. Two reviewers evaluated the quality of the trials and extracted the data independently. RevMan 5.4 software was used for meta-analyses. The primary outcome was a change in 24-hours urinary total protein (24 h TUP).

Results

26 RCTs with 1824 participants were identified. Studies were assessed using the Cochrane risk of bias tool. The overall effects showed that TGs was compared with the controls, TGs showed significant effects in reducing 24 h TUP [WMD = -0.84, 95 % CI (-1.09, -0.59)], elevating serum albumin [WMD = 2.88, 95 % CI (1.87, 3.90)], and the total efficiency [OR = 4.08, 95 % CI (2.37, 7.04)]. This effect was consistent across the subgroups of period of intervention.

Conclusions

The present research showed that TGs was significantly associated with improvement of renal function in patients with DN. TGs offers a novel approach to the treatment of DN, more high-quality RCTs are needed for a better understanding of the role of TGs in DN therapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02487-8.

Efficacy and Safety of Tripterygium Glycoside in the Treatment of Diabetic Nephropathy: A Systematic Review and Meta-Analysis Based on the Duration of Medication

AIM

The aim of this study was to assess the clinical efficacy and safety of Tripterygium-derived glycosides (TG) after 3-month and 6-month of treatments of diabetic nephropathy (DN) and to resolve the conflict between medicine guidance and clinical practice for TG application.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials involving TG application in treating DN. We extensively searched PubMed, Cochrane Library, CNKI, VIP, Wan-Fang, CBM, Chinese Clinical Trial Registry, and WHO International Clinical Trial Registration Platform till November 2020, along with grey literature for diabetes and all other relevant publications to gather eligible studies. Based on the preset inclusion and exclusion criteria, document screening, quality assessment of methodology, and data extraction was conducted by two researchers independently. The methodological quality was assessed by the Cochrane risk test from the Cochrane Handbook 5.2, and then analyses were performed by Review Manager 5.3 (Rev Man 5.3). The quality of output evidence was classified by GRADE.

RESULTS

Thirty-one eligible studies (2764 patients) were included for this meta-analysis. Our study results showed a comparable significant decrease in the 24 h-UTP and blood creatinine levels in DN patients from both 3-month and 6-month TG treatment groups, compared with the routine symptomatic treatment alone. To the contrary of the findings from the included studies, our results showed that the occurrence of serious adverse reaction events was significantly higher in the TG treated group with 6 months of treatment duration compared to that of 3 months of the treatment course. However, the total AR ratio was slightly varied while increasing the percent of severe adverse events. GRADE assessment indicated that the quality of evidence investigating TG-induced adverse reactions was moderate and that for 24 h-UTP and blood creatinine indicators were considerably low.

CONCLUSION

Combinatorial treatment regimen including TG can significantly decrease the pathological indicators for DN progression, while it can also simultaneously predispose the patient to a higher risk for developing severe adverse events, as the medicine guidance indicates. Notably, even in 3-month of course duration smaller percent of severe adverse events can get to a fatal high percent and is likely to increase proportionally as the TG treatment continues. This suggests that TG-mediated DN treatment duration should be optimized to even less than 3 continuous months to avoid adverse event onset-associated further medical complications in DN patients. In clinical practice, serious attention should be paid to these severe side-effects even in a course normally considered safe, and importantly more high-quality studies are urgently warranted to obtain detailed insights into the balance between the efficacy and safety profiles of TG application in treating DN.