| ObjectiveCisplatin(CDDP),as the first-generation platinum antitumor drug,has an irreplaceable position in the treatment of esophageal tumor,lung tumor,and head and neck tumors,but its nephrotoxicity limits its clinical application.The current clinical hydration therapy or reducing the dose of CDDP to alleviate its nephrotoxicity can cause electrolyte disturbance in patients or affect the effect of chemotherapy.Therefore,how to effectively reduce the nephrotoxicity of CDDP without affecting its efficacy is a clinical problem that needs to be solved urgently.Traditional Chinese medicine has achieved good results in the enhancement and detoxification of chemotherapeutic drugs.Studies have reported that the traditional Chinese medicine Astragalus can effectively alleviate drug related nephrotoxicity caused by drugs,and its main active ingredient,Astragaloside Ⅳ(ASⅣ),can alleviate renal interstitial injury in rats,but the specific mechanism of its protection of renal function is not clear.The changes of renal transportersexpressed in renal play a key role in the occurrence of CDDP nephrotoxicity.At present,the researches on transporters mainly focus on the role of organic cation transporter 2(OCT2)in the renal accumulation of CDDP,and some studies have begun to pay attention to the effect of Multiple drug and toxin efflux protein 1(MATE1)on the renal excretion of CDDP,but the relevant research is limited to in vitro and animal experiments,and no research has focused on the role of OCT2/MATE1 in the occurrence of CDDP nephrotoxicity in human.There are few reports focuson whether the mechanism of astragalus protecting renal function is related to transporters.Therefore,this paper takes CDDP chemotherapy patients as the research objects,investigate the effect of Huangqi granules on the CDDP urinary excretion of patients and explores the threshold of CDDP excretion in the event of renal injury;by examining the OCT2/MATE1 inhibitor in CDDP adjuvant chemotherapy(5-hydroxytryptamine 3 receptor antagonist)and renal function changes in patients to explore the role of OCT2/MATE1 in human CDDP nephrotoxicity;further in cell and animal experiments to study the role of OCT2/MATE1 in ASⅣ reducing CDDP renal function.Finally,a Physiologically based pharmacokinetic(PBPK)model was established based on the changes of OCT2/MATE1 to predict the excretion of CDDP in urine,which provided the basis for adjusting the dosage of CDDP to prevent the occurrence of renal injury.Methods1.Clinical Study on Astragalus Granules Relieving Cisplatin NephrotoxicityTwenty-seven patients treated with cisplatin-containing chemotherapy(75mg/m2,1 day administration)were recruited for a randomized controlled study.The control group was given a chemotherapy regimen containing cisplatin(75mg/m2,administered on first day),and the patients in the experimental group were treated with cisplatin(75mg/m2,administered on first day).From 3 weeks before chemotherapy to the start of chemotherapy:Astragalus granules were taken by patients in experiment group(15g each time,twice a day);The rest of the treatment regimens were the same.Primary outcomes:Cumulative urinary excretion within 72 hours after cisplatin infusion,serum creatinine,blood urea nitrogen,β2-microglobulin,cystatin C before and after cisplatin administration;urine microalbuminuria,β2-microglobulin,urine microalbuminuria/creatinine,urinary creatinine;secondary outcomes:the incidence of chemotherapy-related adverse reactions,such as nausea and vomiting,bone marrow suppression,diarrhea,and liver injury.2.A retrospective study on the changes of nephrotoxicity after combined use of cisplatin and 5-HT3 antagonistsA total of 600 patients who received a regimen containing cisplatin and a 5-HT3 antagonist(ondansetron,tropisetron,or ramosetron)were included,and 200 patients were included in each 5-HT3 antagonist group.Relevant medical history information such as gender,age,diagnosis,and renal function-related indicators of the enrolled patients were collected.The changes of serum creatinine before and after chemotherapy in patients were used as the main outcome indicators,the incidence of renal injury after different types of 5-HT3 antagonists combined with cisplatin were analyzed,and the risk factors for renal injury were evaluated.3.The effect of ASⅣ on cisplatin nephrotoxicity and its mechanism Cell experiment:Different concentrations of ASⅣ were added to investigate the effect of ASⅣ on HEK293 cell viability and intracellular cisplatin concentration;Western blotting was used to investigate the effect of ASⅣ on expression of OCT2/MATE1 in HEK293;The effect of ASⅣ on OCT2/MATE1 function was investigated using metformin and p-aminohippuric acid as substrates.Animal experiment:C57BL/6 mice were randomly divided into blank group,control group(cisplatin 25 mg/kg),test group of low-dose(cisplatin 25 mg/kg+ASⅣ 20 mg),test group of high-dose(Cisplatin 25 mg/kg+ASⅣ 40 mg),and ASⅣ was administered 20 days before intraperitoneal injection of cisplatin.The urine of mice was collected for 0-2,2-4,4-6,and 6-8 hours,and the urine volume was accurately measured,the urine drug concentration was determined.After the urine collection was completed,the mice were anesthetized with ether,the orbital blood was collected to determine the serum urea nitrogen and creatinine values,kidney tissue was collected to determine expression of OCT2/MATE1.4.Establishment of PBPK model to predict the effect of ASⅣ on the urinary excretion of cisplatinCollect the physicochemical parameters of cisplatin and ASⅣ,human physiological parameters and pharmacokinetic parameters to building a PBPK model;Optimize the parameters,such as tissue/plasma partition coefficient(Kp),volume of distribution of steady state(Vss),clearance(CL).Established the PBPK model of ASⅣ and cisplatin interaction in PK-Sim,and applied clinical experiments to validate the model.Results1.The results of a single-center,prospective,randomized controlled clinical trial on the interaction of Astragalus granules and cisplatin showed astragalus granules could significantly increase the excretion of cisplatin in urine,and during treatment the incidences of mild hepatotoxicity in patients taking astragalus Granules were significantly lower than those in the control group(P<0.05),and there was no significant difference in the incidence of other adverse reactions between the two groups(P>0.05).The urinary microalbumin/creatinine value was significantly negatively correlated with the excretion of cisplatin in the urine.The ROC curve was used to analyze the urinary microalbumin/creatinine value as the sensitivity and specificity of judging the renal injury of cisplatin.The AUC value of the microalbumin/creatinine value was 0.853;the Youden index value of the ROC curve was calculated,indicating that the cumulative urinary excretion of cisplatin was less than 27.7 mg is the threshold value for kidney injury.2.The percentage of creatinine in the ondansetron group was significantly higher than that of tropisetron when ondansetron,tropisetron,and ramosetron were combined with cisplatin.The incidence of grade≥2 renal injury in the ondansetron group was higher than that in the tropisetron and ramosetron groups.The results of multivariate analysis suggested that the dose of cisplatin was an independent risk factor for cisplatin nephrotoxicity.3.ASⅣ can significantly increase the activity of HEK293 cells;different concentrations of ASⅣ can decrease the intracellular cisplatin uptake by 2.64 times.ASⅣ can increase the expression of uptake transporter OCT2 and efflux transporter MATE 1;The effect on the function of OCT2/MATE 1 showed that ASⅣ could significantly reduce the concentrations of metformin and p-amino hippuric acid in HEK293.The results of animal experiments suggest that ASⅣ can significantly increase the cumulative excretion of cisplatin in the urine of mice,and the maximum increase fold is 3.74 times.The pathology results showed ASⅣ can reduce the damage of kidney.The western blotting results indicated that the expression of OCT2/MATE1 in the kidneys of mice was significantly increased after administration of ASⅣ.4.The PBPK mode of ASⅣ-cisplatin interaction is well established and the predicted value of the model fits well with the measured data.This model can be used to predict the excretion of cisplatin in the urine of patients after given different doses of cisplatin and Astragalus granules.ConclusionsAstragalus granules can increase the cumulative excretion of cisplatin in the patient’s urine and alleviate nephrotoxicity.When the cumulative excretion of cisplatin in the urine is less than 27.7 mg,the renal function may be damaged;Urine microalbumin/creatinine value can be used as an index to evaluate early renal injury.Through in vitro and in vivo experiments,it was concluded that ASⅣ enhanced cell activity and increased the excretion of cisplatin in the urine of mice,which was related to the increased expression of OCT2/MATE1 by ASⅣ,especially the increase in the expression or function of MATE 1.The PBPK model of the interaction of ASⅣ and cisplatin can be used to predict the excretion of cisplatin in urine after patients are given different doses of cisplatin,after compared with the threshold value of urinary excretion to cause renal injury,this model can be used to prevent or slow down cisplatin relate kidney injury. |
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