Acupuncture Application in Chronic Kidney Disease and its Potential Mechanisms

Therapeutic effects of acupuncture therapy for kidney function and common symptoms in patients with chronic kidney disease: a systematic review and meta-analysis

Purpose: The number of clinical reports of acupuncture therapy in chronic kidney disease (CKD) is gradually increasing. This systematic review and meta-analysis aim to examine the therapeutic role of acupuncture therapy in kidney function and common symptoms in CKD patients.Methods: We searched Embase, PubMed, Scopus, Web of Science, China National Knowledge Infrastructure, WanFang, and WeiPu for randomized controlled trials comparing acupuncture treatment with control or placebo groups. We assessed the effect of acupuncture therapy in CKD patients using a meta-analysis with the hartung-knapp-sidik-jonkman random effects model. In addition, we visualized keyword co-occurrence overlay visualization with the help of VOSviewer software to describe the research hotspots of acupuncture therapy and CKD.Results: A total of 24 studies involving 1494 participants were included. Compared to the control group, acupuncture therapy reduced serum creatinine levels (standardized mean difference [SMD]: -0.57; 95% CI -1.05 to -0.09) and relieved pruritus (SMD: -2.20; 95% CI -3.84, -0.57) in patients with CKD, while the TSA showed that the included sample size did not exceed the required information size. The included studies did not report acupuncture-related adverse events.Conclusions: Acupuncture is an effective and safe treatment for improving kidney function and relieving pruritic symptoms in patients with CKD, but the very low evidence may limit this conclusion. The TSA suggests that high-quality trials are needed to validate the efficacy of acupuncture therapy.

An Apriori algorithm-based association rule analysis to identify acupoint combinations for treating uremic pruritus

Objective

Uremic pruritus (UP) is a prevalent and troublesome condition affecting individuals with end-stage renal failure, which results in intense pruritus, depression, as well as poor quality of sleep, significantly impacting their quality of life. According to previous studies, acupuncture and acupoint stimulation have been shown to provide additional benefits in treating UP in dialysis patients. In addition, using acupoints combination may yield superior effectiveness compared to utilizing a singular acupoint. To investigate the potential correlations between acupoint combinations, an association-rule analysis was employed.

Materials and Methods

Apriori algorithms stand out as highly potent techniques for identifying associations in databases; this study utilized an association rule mining to examine the association rules of key acupoint groupings that could be employed for treating UP.

Results

The analysis utilized information derived from the meta-analysis encompassing 40 randomized controlled trials that used acupuncture to treat UP. In total, 64 acupoints were analyzed, and 71 association rules were found. The following acupoint combinations: Auricular shenmen (TF4), Quchi (LI11), and Geshu (BL17); Auricular heart (Extra14), Sanyinjiao (SP6), and Auricular lung (CO14); and Auricular heart (Extra14), Xuehai (SP10), and Auricular lung (CO14) showed the strongest associations.

Conclusion

Acupoints involving Auricular shenmen (TF4), Quchi (LI11), Geshu (BL17), Auricular heart (Extra14), Sanyinjiao (SP6), Auricular lung (CO14), and Xuehai (SP10) can be regarded as the core combination of acupuncture points for managing UP.

Far-infrared stimulation of Neiguan acupoints improves heart rate variability and ameliorate fatigue in hemodialysis patients: A randomized trial

BACKGROUND

In 2018, 84 615 patients in Taiwan received hemodialysis, of which about 62% to 97% suffered from fatigue. Fatigue caused by hemodialysis may be mental or physical. However, the detailed mechanism remains unclear. This study aimed to evaluate whether far-infrared stimulation of the Neiguan acupoint (P6) could effectively reduce fatigue and improve heart rate variability (HRV) in hemodialysis patients.

METHODS

We conducted a two-arm, randomized trial in a hemodialysis center between March 2015 and March 2016. A total of 73 hemodialysis patients were included and were randomly assigned to an experimental group (n = 37) and a control group (n = 36). The experimental group received far-infrared radiation on Neiguan acupoint during hemodialysis for 12 weeks. The outcomes were fatigue level and HRV.

RESULTS

All patients showed moderate fatigue ( M = 26.00 ± 13.01, range = 0-78) at baseline. Far-infrared stimulation on Neiguan acupoint significantly reduced overall fatigue ( β = 24, p < 0.001) and improved HRV ( β = 74.36, p < 0.001). Compared to the control group, the experiment group had significantly reduced fatigue levels in all aspects such as reduced energy and motivation ( β = -2.97, p < 0.001), reduced physical strength ( β = -1.28, p < 0.01), reduced mental capability ( β = -2.38, p < 0.001), reduction in daily activities ( β = -1.48, p < 0.01), depressed mood and loss of control ( β = -1.21, p < 0.05) as well as increased autonomous nervous system activity ( β = 14.71, p < 0.01) in the third month of stimulation.

CONCLUSION

Far-infrared stimulation of the Neiguan acupoints effectively reduces fatigue and increases autonomic nervous system activity in hemodialysis patients.

Effect of Needling at Selected Acupuncture Points (GB39, BL17, LR13) on Hemoglobin Levels in Anemia: a Randomized Placebo Controlled Study

Iron deficiency anemia (IDA) is an important public health issue in India. This study was performed to determine the impact of acupuncture at the GB39, BL17, and LR13 points on hemoglobin levels, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and red cell distribution width (RDW) in people with IDA. One hundred women with IDA were randomly allocated to the acupuncture group (AG) or placebo control group (PCG). For 30 minutes per day, daily for 2 weeks, the AG received acupuncture at GB39, BL17, and LR13, while the PCG received needling at non-acupuncture points. Outcomes were assessed before and after the intervention. We found a significant increase (p < 0.001) in hemoglobin level (AG 10.39-11.38 g/dl, effect size 0.785; PCG 10.58-10.40 g/dl, effect size 0.191), MCH (AG 25.69-27.50 fl, effect size 0.418; PCG 27.43-27.23 fl, effect size 0.058), and RDW (AG 15.12-16.41 fl, effect size 0.626; PCG 14.91-14.94 fl, effect size 0.017) in the AG compared to the PCG. Results suggest that needling at the GB39, BL17, and LR13 acupuncture points is more effective in treating people with IDA than needling at non-acupuncture points.

Effects of electroacupuncture at KI3 and ST36 on the hypothalamic paraventricular nucleus in a rat model of chronic glomerulonephritis

OBJECTIVE

The hypothalamic paraventricular nucleus (PVN) acts as a critical integrating center of endocrine/autonomic responses and regulates visceral functional activities. However, its involvement in electroacupuncture (EA) treatment of chronic glomerulonephritis (CGN) remains unclear.

METHODS

Over four experiments, we randomized 111 rats into: control, untreated model (CGN) or EA-treated model (CGN + EA) groups, a model group receiving EA after PVN damage (CGN + EA + Lesion) or untreated model groups injected with adeno-associated viral vectors encoding human M4 muscarinic receptor (CGN + hM4D) or enhanced green fluorescent protein (CGN + EGFP). CGN was modeled by intraperitoneal injection of bovine serum albumin for 2 weeks. Rats in the CGN + EA and CGN + EA + Lesion groups received EA at bilateral ST36 and KI3 for 14 days. Urine/serum samples were collected to evaluate inflammatory factors and changes in renal function.

RESULTS

EA inhibited the release of interleukin (IL)-6, tumor necrosis factor (TNF)-α and IL-1β, and decreased urine protein (PRO), creatinine (Cre) and blood urea nitrogen (BUN) levels. PVN damage influenced the effect of EA on the levels of these parameters. EA appeared to inhibit the firing frequency and spectral energy of PVN neurons. In the viral vector experiment, levels of PRO, Cre, IL-6, IL-1β and TNF-α in the CGN group were increased in CGN versus control groups (p < 0.0001), decreased in CGN + hM4D versus CGN groups (p < 0.05) and did not differ between CGN + EGFP and control groups (p > 0.05).

CONCLUSION

Our findings indicate that EA at ST36 and KI3 improves CGN in this rat model by weakening the activity of PVN neurons, alleviating impairment of renal function impairment and restricting the release of inflammatory factors.

Patient-Reported Outcomes Measurement Information System -29 Domains Interaction in Chronic Musculoskeletal Pain During Acupuncture: A Pilot Study

Objective

This pilot study explored interactions of domains of physical, psychologic, and social factors in the Patient-Reported Outcomes Measurement Information System® (PROMIS®)-29 system and their dynamic changes during acupuncture treatment of chronic musculoskeletal pain.

Materials and Methods

PROMIS-29 profile, version 2.1 was applied among participants with chronic musculoskeletal pain, who received acupuncture treatment for 5 weeks. Data from function-oriented and symptom-oriented domains as well as changes in pain intensity were evaluated at weeks 0, 3, and 5, in 9 patients who completed full sessions. Scores of the domains were analyzed by hierarchical cluster analysis at each timepoint to identify the patterns of interactions of PROMIS domains.

Results

Hierarchical cluster analysis revealed the existence of 2 main clusters: one consisting of pain, fatigue, and emotional domains; the other comprising physical function and social domains. The general pattern was stable but interactions were found throughout the treatment. The score for sleep disturbance did not improve but was correlated with different domains at varying stages of treatment.

Conclusions

Interaction between 2 clusters of pain with fatigue and emotional domains; and physical function with social domains showed that acupuncture produces holistic reductions in chronic musculoskeletal pain. However, the limitation of sample size and bias in this pilot study requires future research on the need to adopt an interdisciplinary and holistic approach to the recovery of patients with chronic musculoskeletal pain, who have dynamic needs.

Acupuncture for Uremic Pruritus: A Systematic Review and Meta-Analysis

Uremic pruritus (UP) is a chronic disease that can seriously affect the quality of life of dialysis patients. Acupuncture is a non-medication therapy that has been used to treat pruritus disorders. This systematic review aimed to evaluate the efficacy and safety of acupuncture for the treatment of UP. A total of nine Chinese and English databases were searched from their inception to December 31, 2021, and 214 studies were retrieved. Finally, seven randomized controlled trials (n=504) were included in the meta-analysis performed using RevMan V.5.3. Results included effective rate, recurrence rates, and adverse events. Compared with conventional treatment, acupuncture was more effective in treating UP (risk ratio [RR]=1.28, 95% confidence interval [CI]=1.09 to 1.50, P=0.003). The results were consistent after sensitivity analysis (RR=1.38, 95% CI=1.21 to 1.57, P<0.00001). In subgroup analysis, the efficacy rates of acupuncture and medications (oral and topical) were comparable (RR=1.20, 95% CI=0.98 to 1.47, P=0.07). Acupuncture combined with hemodialysis was more effective than hemodialysis alone in relieving pruritus (RR=1.42, 95% CI=1.18 to 1.72, P=0.0002). Adverse events were reported in only three studies, including one case of hyperphosphatemia in the medications group (RR=0.29, 95% CI=0.01 to 7.06, P=0.45). None of the studies reported recurrence rates. In conclusion, acupuncture is a safe treatment modality for patients with UP receiving hemodialysis that can effectively improve UP symptoms, and acupuncture in combination with hemodialysis has more efficacy than hemodialysis alone in improving the UP symptoms.

Mechanisms underlying acupuncture therapy in chronic kidney disease: A narrative overview of preclinical studies and clinical trials

Chronic kidney disease (CKD) is associated with high incidence, low awareness, and high disability rates among the population. Moreover, the disease significantly affects the physical and mental health of patients. Approximately 25% of patients with CKD develop end-stage renal disease (ESRD) within 20 years of diagnosis and have to rely on renal replacement therapy, which is associated with high mortality, heavy economic burden, and symptoms including fatigue, pain, insomnia, uremia pruritus, and restless leg syndrome. Currently, the means to delay the progress of CKD are insufficient; therefore, developing strategies for delaying CKD progression has important practical implications. In recent years, more and more people are accepting the traditional Chinese medical technique "acupuncture." Acupuncture has been shown to improve the uncomfortable symptoms of various diseases through stimulation (needling, medicinal moxibustion, infrared radiation, and acupressure) of acupoints. Its application has been known for thousands of years, and its safety and efficacy have been verified. As a convenient and inexpensive complementary therapy for CKD, acupuncture has recently been gaining interest among clinicians and scientists. Nevertheless, although clinical trials and meta-analysis findings have demonstrated the efficacy of acupuncture in reducing albuminuria, improving glomerular filtration rate, relieving symptoms, and improving the quality of life of patients with CKD, the underlying mechanisms involved are still not completely understood. Few studies explored the correlation between acupuncture and renal pathological diagnosis. The aim of this study was to conduct a literature review summarizing the currently known mechanisms by which acupuncture could delay the progress of CKD and improve symptoms in patients with ESRD. This review help provide a theoretical basis for further research regarding the influence of acupuncture on renal pathology in patients with CKD, as well as the differences between specific therapeutic mechanisms of acupuncture in different renal pathological diagnosis. The evidence in this review indicates that acupuncture may produce marked effects on blocking and reversing the critical risk factors of CKD progression (e.g., hyperglycemia, hypertension, hyperlipidemia, obesity, aging, and anemia) to improve the survival of patients with CKD via mechanisms including oxidative stress inhibition, reducing inflammatory effects, improving hemodynamics, maintaining podocyte structure, and increasing energy metabolism.

Clinical Efficacy and Safety of Chinese Herbal Medicine in the Treatment of Uremic Pruritus: A Meta-Analysis of Randomized Controlled Trials

Uremic pruritus is a disturbing and refractory symptom in patients with advanced chronic kidney disease. Chinese herbal medicine has been reported to alleviate uremic pruritus. To investigate the effects of Chinese herbal medicine, we conducted a systematic review and meta-analysis on patients with uremic pruritus. We searched databases (prior to 3 May 2022) for randomized controlled trials on the effects of Chinese herbal medicine in treating uremic pruritus. Our meta-analysis included 3311 patients from 50 randomized controlled trials. In patients with uremic pruritus, adjunctive Chinese herbal medicine significantly improved overall effectiveness (risk ratio 1.29, 95% CI 1.23 to 1.35), quality of life, renal function, reduced pruritus score, and inflammatory biomarkers compared to control groups with hemodialysis alone or with anti-pruritic treatments. Chinese herbal medicine treatment showed a time-dependent tendency in improving the visual analog scale of dialysis patients. Compared to control groups, no significantly higher risk of adverse events in patients taking Chinese herbal medicine (risk ratio 0.60, 95% CI 0.22 to 1.63). Chinese herbal medicine appears to be effective and safe in complementing the treatment of patients with uremic pruritus.

Effect of Acupuncture on Functional Capacity in Patients Undergoing Hemodialysis: A Patient-Assessor Blinded Randomized Controlled Trial

Decreased functional capacity (FC) in patients undergoing hemodialysis (HD) is associated with adverse health events and poor survival. Acupuncture is recognized as a safe and effective integrative treatment. The aim of this study is to evaluate the effect of acupuncture treatment on the FC in chronic kidney disease with GFR category 5 (CKG G5) patients undergoing HD. In this patient-assessor blinded randomized controlled trial, seventy-two KF patients were randomly assigned to experimental (n = 24), placebo (n = 24) and control groups (n = 24). The primary outcome was the improvement in FC assessed by the 6-Minute Walk Test (6-MWT). Secondary outcomes included assessment of peripheral muscle strength by the Handgrip Strength Test (HGS) and the 30-Second Sit-to-Stand Test (STS-30) at baseline, after treatment and at 12-week follow up. A mixed ANOVA with interaction time*group was used. The experimental group increased walk distance (p < 0.001), lower limbs strength (p < 0.001) and handgrip strength (p = 0.012) after nine acupuncture sessions and stabilized in the follow-up (p > 0.05). In the placebo and control groups the 6-MWT and 30STS results decreased (p < 0.001) and the HGS scores did not change through time (p > 0.05). Acupuncture treatment improved FC and muscle strength in patients undergoing HD.

Tongue Diagnosis Index of Chronic Kidney Disease

BACKGROUND

To apply non-invasive Automatic Tongue Diagnosis System (ATDS) in analyzing tongue features in patients with chronic kidney disease (CKD).

METHODS

This was a cross-sectional, case-controlled observational study. Patients with CKD who met the inclusion and exclusion criteria were enrolled and divided into the following groups according to renal function and dialysis status: non-dialysis CKD group; end-stage renal disease (ESRD) group; and control group. Tongue images were captured and eight tongue features-shape, color, fur thickness, saliva, fissure, ecchymosis, teeth marks, and red dots-were imaged and analyzed by ATDS.

RESULTS

117 participants (57 men, 60 women) were enrolled in the study, which included 16 in control group, 38 in non-dialysis CKD group, and 63 in ESRD group. We demonstrated significant differences in the fur thickness (p = 0.045), color (p = 0.005), amounts of ecchymosis (p = 0.010), teeth marks (p = 0.016), and red dot (p < 0.001) among three groups. The areas under receiver operating characteristic curve for the amount of ecchymosis was 0.757 ± 0.055 (95% confidence interval, 0.648-0866; p < 0.001). Additionally, with increase in ecchymosis by one point, the risk of CKD dialysis rose by 1.523 times (95% confidence interval, 1.198-1.936; p = 0.001). After hemodialysis, the amount of saliva (p = 0.038), the area of saliva (p = 0.048) and the number of red dots (p = 0.040) were decreased significantly among patients with ESRD. On the contrary, the percentage of coating (p = 0.002) and area of coating (p = 0.026) were increased significantly after hemodialysis.

CONCLUSION

Blood deficiency and stasis with qi deficiency or blood heat syndrome (Zheng pattern) is common in patients with CKD. The risk of CKD dialysis increases with increasing ecchymosis. Hemodialysis can affect saliva, tongue coating, and relieve heat syndrome among ESRD patients.

Chronic Intractable Pruritus in Chronic Kidney Disease Patients: Prevalence, Impact, and Management Challenges - A Narrative Review

Chronic kidney disease (CKD) is recognized as a leading public health problem and causes numerous health complications. One of the most common and burdensome dermatological symptoms affecting patients undergoing dialysis is CKD-associated pruritus (CKD-aP). This condition not only has a negative impact on sleep, mood, daily activities, and quality of life but also increases the mortality risk of hemodialyzed patients. Despite that, this condition is greatly underestimated in clinical practice. Due to the complex and still not fully understood etiopathogenesis of CKD-aP, the choice of an effective therapy remains a challenge for clinicians. Most common therapeutic algorithms use topical treatment, phototherapy, and various systemic approaches. This review aimed to summarize most recent theories about the pathogenesis, clinical features, and treatment of CKD-aP.

Combined effects of acupuncture and auricular acupressure for relieving cancer-related fatigue in patients during lung cancer chemotherapy: A protocol for systematic review and meta-analysis

BACKGROUND

Increasing attention has been paid to acupuncture and auricular acupressure as alternative strategies for cancer related fatigue (CRF) management. Therefore, we design this systematic review and meta-analysis to explore the efficacy and safety of acupuncture and auricular acupressure for relieving CRF in patients during lung cancer chemotherapy.

METHODS

From the inception to August 2021, the Web of Science, EMBASE, PubMed, and Cochrane Library electronic databases were searched using the key phrases "acupuncture", "auricular acupressure", and "lung cancer" for all relevant trials. Trials that compared acupuncture (including electroacupuncture) and auricular acupressure with acupuncture alone were included. The primary outcome was the measurement of the CRF symptoms. Secondary outcome measures were physical activity, quality of life, and adverse events. A P value of <.05 was considered to be statistically significant.

RESULTS

It will be the first such study and will obtain evidence for utilizing acupuncture and auricular acupressure for lung cancer patients.

CONCLUSION

Combined acupuncture and auricular acupressure may be effective for relieving CRF in patients during lung cancer chemotherapy.

The Therapeutic Strategies for Uremic Toxins Control in Chronic Kidney Disease

Uremic toxins (UTs) are mainly produced by protein metabolized by the intestinal microbiota and converted in the liver or by mitochondria or other enzymes. The accumulation of UTs can damage the intestinal barrier integrity and cause vascular damage and progressive kidney damage. Together, these factors lead to metabolic imbalances, which in turn increase oxidative stress and inflammation and then produce uremia that affects many organs and causes diseases including renal fibrosis, vascular disease, and renal osteodystrophy. This article is based on the theory of the intestinal-renal axis, from bench to bedside, and it discusses nonextracorporeal therapies for UTs, which are classified into three categories: medication, diet and supplement therapy, and complementary and alternative medicine (CAM) and other therapies. The effects of medications such as AST-120 and meclofenamate are described. Diet and supplement therapies include plant-based diet, very low-protein diet, probiotics, prebiotics, synbiotics, and nutraceuticals. The research status of Chinese herbal medicine is discussed for CAM and other therapies. This review can provide some treatment recommendations for the reduction of UTs in patients with chronic kidney disease.

Review of Traditional Chinese Medicines for Common Complications Related to Hemodialysis: An Evidence-Based Perspective

Renal replacement therapy is an important therapy for prolonging life in end-stage renal disease (ESRD) populations, and, in Taiwan, hemodialysis (HD) is the choice for most patients with ESRD. Although HD is effective for prolonging life, it is sometimes associated with complications that patients and doctors have to cope with every day, such as intradialytic hypotension, dialysis disequilibrium syndrome, and muscle cramps. Traditional Chinese medicine (TCM) is a complementary and alternative therapy that has been recognized for its efficacy in treating a variety of diseases by the World Health Organization. Nowadays, the clinical practice of TCM for HD-related complications has received attention for its effectiveness and safety. In this article, we summarize the TCM viewpoint and different TCM interventions for HD-related complications, such as Chinese herbal medicine, acupuncture, herbal acupoint therapy, auricular acupoints, and moxibustion. In the ESRD population, TCM is able to balance Yin and Yang, prevent cardiovascular accidents, control blood pressure, and relieve pain. More importantly, TCM may also improve common HD-related complications such as uremic symptoms, imbalance of electrolyte and fluid status, insomnia, and malnutrition. The mechanism of TCM is considered related to the regulation of autonomous functions and the activation of biologically active chemical substances. According to the studies noted in this review article, TCM has been proven effective for HD-related complications. However, more well-designed and rigorous research will be necessary to reveal the underlying mechanisms in the future.

Acupuncture to treat asymptomatic hyperuricemia: A protocol for systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Hyperuricemia (HUA) plays an important role in metabolic syndrome, cardiovascular disease, and kidney disease. HUA without resulting gout is referred to as asymptomatic HUA. The purpose of the present systematic review protocol is to provide methods to assess the effectiveness and safety of acupuncture-based treatment for asymptomatic HUA.

METHODS

To identify randomized controlled trials (RCTs) involving acupuncture-based treatment for asymptomatic HUA, a search will be carried out using the following eight electronic databases: MEDLINE, EMBASE, Cochrane Library, Korea Med, Oriental Medicine Advanced Searching Integrated System, Korean Studies Information Service System, China National Knowledge Infrastructure, and Japanese Institutional Repositories Online. Manual search and email contact with the author will also be conducted if necessary. Studies will be selected based on predefined criteria and summarized data regarding study participants, interventions, control groups, outcome measures, side effects, and risk of bias. No language restrictions will be imposed. Studies that evaluated any type of acupuncture will be eligible for inclusion, and the primary outcome will be the blood uric acid level. The methodological quality of the included RCTs will be assessed using the Cochrane risk of bias tool.

RESULTS

The present study will evaluate the efficacy and safety of acupuncture to treat HUA.

CONCLUSION

Our findings will establish the evidence for acupuncture-based treatment of HUA and will be informative for patients with HUA, clinicians, policy makers, and researchers.

REGISTRATION NUMBER

reviewregistry1054.

Mechanism of herbal medicine on hypertensive nephropathy (Review)

Hypertensive nephropathy is the most common complication of hypertension, and is one of the main causes of end-stage renal disease (ESRD) in numerous countries. The basic pathological feature of hypertensive nephropathy is arteriolosclerosis followed by renal parenchymal damage. The etiology of this disease is complex, and its pathogenesis is mainly associated with renal hemodynamic changes and vascular remodeling. Despite the increased knowledge on the pathogenesis of hypertensive nephropathy, the current clinical treatment methods are still not effective in preventing the development of the disease to ESRD. Herbal medicine, which is used to relieve symptoms, can improve hypertensive nephropathy through multiple targets. Since there are few clinical studies on the treatment of hypertensive nephropathy with herbal medicine, this article aims to review the progress on the basic research on the treatment of hypertensive nephropathy with herbal medicine, including regulation of the renin angiotensin system, inhibition of sympathetic excitation, antioxidant stress and anti-inflammatory protection of endothelial cells, and improvement of obesity-associated factors. Herbal medicine with different components plays a synergistic and multi-target role in the treatment of hypertensive nephropathy. The description of the mechanism of herbal medicine in the treatment of hypertensive nephropathy will contribute towards the progress of modern medicine.

Nonpharmacologic Treatments for Opioid Reduction in Patients With Advanced Chronic Kidney Disease

Opioid analgesics carry risk for serious health-related harms in patients with advanced chronic kidney disease (CKD) and end-stage kidney disease. In the general population with chronic noncancer pain, there is some evidence that opioid reduction or discontinuation is associated with improved pain outcomes; however, tapering opioids abruptly or without providing supportive interventions can lead to physical and psychological harms and relapse of opioid use. There is emerging evidence that nonpharmacologic treatments such as psychosocial interventions, acupuncture, and interdisciplinary pain management programs are effective approaches to support opioid dose reduction in patients experiencing persistent pain, but research in this area still is relatively new. This review describes the current evidence for nonpharmacologic interventions to support opioid reduction in non-CKD patients with pain and discusses the application of the available evidence to patients with advanced CKD who are prescribed opioids to manage pain.

Nonopioid Approaches to Pain Management in Chronic Kidney Disease

Patients with chronic kidney disease (CKD) and end-stage renal disease experience high pain and symptom burden, but management of chronic pain in this population remains challenging. Recent studies have shown a high rate of opioid prescription and use in patients with kidney disease. However, the concern for opioid-related morbidity and mortality suggests a need to reconsider the safety and efficacy of opioid use in patients with CKD. In this review, we describe the current approaches to pain management in CKD, highlight the evolving opioid-related risks and kidney-specific concerns, and offer both pharmacologic and nonpharmacologic nonopioid strategies for pain management in patients with kidney disease, emphasizing the importance of using a multimodal approach to optimize pain control.

Acupoint injection treatment for non-dialysis dependent chronic kidney disease: A meta-analysis of randomized controlled trials

AIM

To analyze the effects of acupoint injection in the treatment of non-dialysis dependent chronic kidney disease through a systematic review with meta-analysis.

METHODS

This systematic review with meta-analysis was conducted following the recommendations of the declaration of PRISMA. Full-text literature of randomized controlled trial of acupoint injection therapy for non-dialysis chronic kidney disease was searched in PubMed, Embase, Cochrane Library, China National Knowledge Internet, the Chinese Scientific Journal Database, the Wanfang Database, China Biology Medicine database. The efficacy and safety of acupoint injection for non-dialysis chronic kidney disease were evaluated.

RESULTS

Seventeen studies containing 1414 patients met the criteria. The results shows that acupoint injection combined with basic treatment can significantly improve the levels of Ccr (WMD = 4.81; 95% CI:2.54 to 7.08) and Hb (WMD = 4.56; 95% CI:1.72 to 7.39), reduce the levels of BUN (WMD = -0.90; 95% CI: -1.26 to -0.54)and Scr (WMD = -7.66; 95% CI: -12.39 to -2.93), and improve the effective rate (OR = 3.12; 95% CI: 2.29 to 4.26).

CONCLUSION

Our current analysis showed that combined acupoint injection therapy can reduce the levels of BUN and Scr, and increase Ccr and Hb in non-dialysis CKD patients. However, the existing evidence is still insufficient due to the high risk of included trial bias, and future research needs to improve methodological quality.Registration number: CRD42020168143.

Moxibustion as an Adjuvant Therapy for Chronic Kidney Disease: A Systematic Review and Meta-Analysis of 23 Randomized Controlled Trials

OBJECTIVE

This systematic review aims to investigate the efficacy and safety of moxibustion for chronic kidney disease (CKD).

METHODS

Nine databases were searched to identify relevant evidence up to March 8, 2020. Randomized controlled trials (RCTs) that tested moxibustion + basic treatments versus basic treatments alone for patients with CKD and reported, at least, one of the outcomes of interest were included. In the meta-analyses, the mean differences (MDs) and 95% confidence intervals (CIs) were used to measure the effect size.

RESULTS

Twenty-three RCTs (n = 1571) with a moderate to high risk of bias were included. The pooled estimates showed that compared with the controls, patients after moxibustion had a significant reduction in serum creatinine (MD -17.34 μmol/L, 95% CI -28.44 to -6.23; I 2 = 87%), 24-hour urine protein excretion (MD -0.75 g/h, 95% CI -1.07 to -0.42; I 2 = 84%), and blood urea nitrogen (MD -0.63 mmol/L, 95% CI -1.09 to -0.18; I 2 = 37%) and a significant improvement in the quality of life (MD 10.18, 95% CI 3.67 to 16.69; I 2 = 57%). Moxibustion did not show a significant effect on the estimated glomerular filtration rate (eGFR), creatinine clearance, or hemoglobin. The subgroup analyses showed that a longer course of moxibustion (>8 weeks) and indirect moxibustion had a greater effect on reducing serum creatinine. The effect of moxibustion on blood urea nitrogen changed to be nonsignificant after excluding RCTs with a high risk of bias (MD -0.96 mmol/L, 95% CI -2.96 to 1.03). Only one adverse event of burn was reported.

CONCLUSIONS

This systematic review suggests that, as an adjuvant therapy, moxibustion may improve serum creatinine, urinary protein excretion, blood urea nitrogen, and quality of life in patients with CKD. Moxibustion may not have effects on eGFR, creatinine clearance, or hemoglobin. The quality of evidence is weakened by the limitations of risk of bias, heterogeneity, and imprecision.

The Role of Opioids in Pain Management in Elderly Patients with Chronic Kidney Disease: A Review Article

Chronic kidney disease (CKD) is a global public health problem. Pain is one of the most generally experienced symptoms by CKD patients. Pain management is a key clinical activity; nonetheless, insufficient pain management by health professionals keeps it up. Opioids as pain relievers are a class of naturally-derived and synthetic medications. They act through interactions with receptors in peripheral nerves. Numerous pharmacokinetic alterations happen with aging that influence drug disposition, metabolism, and quality of life. Acetaminophen alone, or combined with low-potency opioid dose is regarded as the safest pain-relieving choice for CKD. Morphine and codeine are probably eluded in renal impairment patients and used with excessive carefulness. Tramadol, oxycodone, and hydromorphone can be used by patient monitoring, while methadone, transdermal fentanyl, and buprenorphine seem to be safe to use in older non-dialysis patients with renal impairment. Consistent with the available literature, the main aim of this review was to explore the occurrence of chronic pain and its opioid treatment in CKD patients. According to this review, more and well-made randomized controlled trials are necessary to find appropriate opioid doses and explore the occurrence of side effects.

Effects of Herbal Medicines on Pain Management

Pain is an unpleasant sensory and emotional experience in many diseases and is often caused by intense or damaging stimuli. Pain negatively affects the quality of life and increases high health expenditures. Drugs with analgesic properties are commonly used to relieve pain, but these Western medications could be overwhelmed by side effects including tolerance and addiction. Herbal medicines may provide alternative measures for pain management. In this review paper, after introduction of Chinese medicine theory and treatment modality, emphasis is placed on the application of Chinese herbs and herbal formulations in pain management. Three of the most commonly used herbs, i.e., Corydalis yanhusuo, Ligusticum chuanxiong, and Aconitum carmichaeli, are reviewed. Subsequently, using this ancient medical remedy, Chinese herbal formulation in treating common medical conditions associated with pain, such as headache/migraine, chest pain, abdominal pain, low back pain, neuropathic pain, osteoarthritis, and cancer pain, is presented. Chinese herbal medicines could be considered as a complementary and integrative approach in the modern armamentarium in combating pain.

Acupuncture for patients with chronic pruritus: protocol of a systematic review and meta-analysis

INTRODUCTION

Chronic pruritus (CP) frequently occurs in many skin and systemic diseases, and adversely affects quality of life. This systematic review aims to evaluate treatment effects of acupuncture on CP.

METHODS AND ANALYSIS

An electronic and manual search will be conducted for all acupuncture treatments for CP, from the inception date of predefined database up to 28 February 2020. Databases include PubMed, Embase, Springer, Web of Science, the Cochrane Library, the World Health Organization International Clinical Trial Registration Platform, the Chinese Medicine Database, the China National Knowledge Infrastructure, the Chinese Biomedical Literature Database, the China Science Journal Database and the Wanfang Database. Other sources, including existing systematic reviews, conference proceedings and reference lists of identified publications will also be searched. Additionally, any clinical randomised controlled trials related to acupuncture treatment for CP, regardless of the publication status and language limitations, will be included. Study selection, data extraction and research quality assessments will be conducted independently by two researchers. The primary outcome measures include the Visual Analogue Scale, Urdu 5D-Itch Scale or other validated scales implemented after at least 2 weeks of treatment. Secondary outcomes include the effective rate, Quality of Life Scale (eg, the EQ-5D third level, the Dermatology Life Quality Index, etc.), Pittsburgh Sleep Quality Index, recurrence rate during the follow-up period and adverse events. If possible, meta-analyses will be performed using RevMan V.5.3 statistical software; otherwise, a descriptive analysis or subgroup analysis will be conducted. The results will be presented as the risk ratio of the binary data and the mean difference (MD) or standardised MD of the continuous data.

ETHICS AND DISSEMINATION

This systematic review protocol does not require formal ethical approval because the data are not personalised. It will be published in peer-reviewed journals and presented at international academic conferences.

PROSPERO REGISTRATION NUMBER

CRD42019136727.

Using Traditional Chinese Medicine to Relieve Asthma Symptoms: A Systematic Review and Meta-Analysis

Studies have demonstrated the effect of acupoint-based interventions in relieving the clinical symptoms of asthma. However, the effect of meridian-based interventions in asthma symptom relief is unknown. This systematic review and meta-analysis determined the effect of multiplex meridian interventions in asthma symptom relief. Eight electronic databases were searched for relevant randomized controlled trials (RCTs) that involved patients with asthma, were published before March 2018, used acupoint stimulation interventions targeting acupoints that correspond to meridians, and considered asthma symptom relief as an outcome. In 204 RCTs that were identified and used in a meta-synthesis, meridians were used 521 times, with the bladder meridian being the most frequently used. Furthermore, 23 RCTs were included in the meta-analysis. Egger's and inconsistency tests revealed no significant differences among the studies (P>0.05). However, the interventions differed significantly in terms of asthma symptom relief effect, as demonstrated by pairwise (odds ratio [OR]=0.28, 95% confidence interval=0.21-0.37) and network (OR=0.18, 95% credibility interval=0.08-0.41) meta-analyses. Surface under the cumulative ranking (SUCRA) revealed that the bladder-conception vessel-governor vessel-stomach multiplex meridian intervention was more effective than non-meridian interventions in relieving asthma symptoms. Additionally, either bladder-conception vessel-stomach or bladder-conception vessel-governor vessel-kidney multiplex meridians may be selected in interventions. This study suggests that practitioners target multiplex meridians, especially the meridians of the bladder and conception vessel, to effectively relieve asthma symptoms.

Transcutaneous Electrical Acupoint Stimulation for Improving Postoperative Recovery, Reducing Stress and Inflammatory Responses in Elderly Patient Undergoing Knee Surgery

Transcutaneous electrical acupoint stimulation (TEAS) is a form of acupuncture treatment that applies electrical stimulation on specific acupoint through cutaneous electrodes. This technique has been used for perioperative anesthesia management as part of after surgery recovery. However, to date, limited data are available for using the TEAS for postoperative recovery in elderly surgical patients. We conducted this prospective randomized sham-control trail to evaluate the efficacy of TEAS in a group of elderly patients receiving knee surgery under epidural anesthesia. 52 subjects were assigned to either the experimental group (Group E) or control group (Group C). The patients in Group E received TEAS at zusanli (ST36), sanyinjiao (SP6), neiguan (PC6), and quchi acupoints (LI11) 30[Formula: see text]min prior to the epidural anesthesia and postoperative day 1 and 2, while patients in Group C received sham TEAS on the same acupoints for 30[Formula: see text]min same as those of Group E. The primary endpoint was the Quality of Recovery-40 questionnaire (QR-40) and the secondary endpoints were the biomarkers level of stress and inflammatory responses and visual analogue scale (VAS). A one-way ANOVA (SNK method) was used in statistic, and [Formula: see text] is considered to be statistically significant. Our data showed that the QoR-40 was significantly lower in Group C than that in Group E at postoperative day 1 ([Formula: see text]); Similarly, Cortisol (COR), Adrenocorticotropic Hormone (ACTH), and C-reactive protein (CRP) were significantly lower in Group E than those of Group C at postoperative day 1, 3, and 7 ([Formula: see text]), while the neutrophil/lymphocyte ratio (N/L) was lower in Group E than that in Group C at postoperative day 1 and 3 ([Formula: see text]). Our results showed that perioperative TEAS administration is able to facilitate the development of postoperative recovery of elderly patients, especially at the early stage after surgery. The reported results are likely to be mediated by the reduction of surgical inflammation and perioperative stress response.

Application of Chinese Medicine in Acute and Critical Medical Conditions

Western medicine is routinely used in developed nations as well as in Eastern countries, where traditional medicine is frequently used by a selection of patients or family member as a complement to mainstream Western medicine. Chinese medicine plays an important role in the treatment of chronic diseases, especially when Western medicine is not very effective. Many published reports have shown that Chinese medicine could also be successfully used in the management of acute and critical illnesses. Chinese medicine has a holistic view of the human body, and emphasizes individualization based on body balance and mind-body interaction and employs herbal medicines and acupuncture. This review paper gives a brief overview of Chinese medicine theory and therapeutic modality and then addresses the application of Chinese medicine in the treatment of acute and critical medical conditions, including epidemics. Using this ancient therapy as a complementary medicine, the management of serious medical conditions, such as SARS, acute heart diseases, and ischemic cerebral stroke, are presented. In order to promote more widespread application of Chinese medicine, well-designed controlled clinical trials are urgently needed to prove its safety and effectiveness.