The Correlation Between The TCM Syndrome Classification Of Chronic Aplastic Anemia And The Imbalance Of T Cell Immune Response

Objective:Dysregulation of T cell immune response is a key pathological mechanism of aplastic anemia(AA).Inhibition of abnormal activation of T cells is an important treatment measure of AA.Some studies have shown that visceral diseases of Traditional Chinese Medicine(TCM)can affect the immune regulation of the body.Spleen deficiency and kidney deficiency are common symptoms elements of AA,and there is no relevant research on whether the two syndrome classification have different effects on immune function.Trough the Chinese medicine to take spleen-tonifying and kidney-invigorating often have a certain effect to treat AA,so treatment of strengthening the spleen and invigorating the kidney may help regulate immune function.The project,which regard the chronic aplastic anemia(CAA)patients with spleen deficiency and blood deficiency syndrome and kidney deficiency and blood deficiency syndrome as research objects,to explore the correlation between TCM syndrome classification and T cell immune response disorder,and to determine the different effects of spleen deficiency and kidney deficiency on the degree of T cell subgroup dysregulation.To take spleen-tonifying and kidney-invigorating traditional Chinese medicine as intervention measures,preliminary explore the mechanism of applying Chinese medicine to regulate T cell immune response to treat AA based on the TCM syndrome classification of spleen deficiency and blood deficiency syndrome and kidney deficiency and blood deficiency syndrome.Methods:1.To retrospectively study the difference between T cell immune response in patients with CAA of spleen deficiency blood deficiency syndrome and kidney deficiency blood deficiency syndrome,and to clarify the correlation between T cell immune response disorder and the TCM syndrome classification.To collect inpatients diagnosed with CAA by clinical manifestations and laboratory tests,the inclusion criteria:?diagnosed as CAA;?from January 2011 to May 2018 inpatient treatment in the Department of Hematology and Oncology,Dongzhimen Hospital,Beijing University of Chinese Medicine;?TCM syndromes are spleen deficiency blood deficiency syndrome or kidney deficiency blood deficiency syndrome;?to detect peripheral blood lymphocyte subsets by flow cytometry;?except for patients with fever,infectious diseases and tumor diseases during hospitalization.The diagnostic criteria for spleen deficiency and blood deficiency syndrome and kidney deficiency and blood deficiency syndrome were according to the diagnostic criteria of the Diagnostic Standards for Deficiency of TCM and the Guideline of Clinical Research of TCM New Drugs and combination with the opinions of industry expert groups,extract the information from the TCM four diagnostic methods from inpatient medical records and to reclassify the syndrome.Compared with healthy adults,to determine the disorder of T lymphocyte subsets(CD4+,CD8+,Treg and CD4+/CD8+ratio)in patients with AA;To analyze the difference of abnormal activation of cytotoxic T cells in patients with spleen deficiency and blood deficiency syndrome and kidney deficiency and blood deficiency syndrome.Through univariate correlation analysis to explored the correlation between age,gender,disease course,whole blood cell analysis,T lymphocyte subsets and TCM syndrome classification,and further used binary logistic regression to analyze independent influencing factors.Collect the cases that can be evaluated for clinical efficacy,and analyze the correlation between the TCM syndrome classification,T cell immune response and clinical efficacy.2.To further explore the mechanism of application of TCM to regulate T cell immune response in the treatment of CAA.20 cases of CAA of kidney deficiency and blood deficiency syndrome or spleen deficiency and blood deficiency syndrome are planned to be included from August 2018 to November 2019,to take spleen-tonifying and kidney-invigorating traditional Chinese medicine as intervention measures,combined with basic Western medicine as appropriate.One course of treatment is 3 months,and two courses of treatment were applied for a total of 6 months.TCM syndrome scores were scored at the time of enrollment,3 months of treatment,and 6 months of treatment.Automatic complete blood count was performed at the time of enrollment and once a month after treatment;flow cytometry was used to detect peripheral blood T cells subsets(CD4+,CD8+,CD4+/CD8+)and T lymphocyte activation status(HLA-DR+ T,CD4+HLA-DR+,CD8+HLA-DR+,CD4+ HLA-DR+/CD4+,CD8+HLA-DR+/CD8+,activated T cells);ELISA method to detect plasma TNF-?,TGF-? and IL-10 cytokines expression before and after treatment.The indicators of security were detected.The primary efficacy parameter was the clinical curative effect of CAA;Secondary parameters include the improvement rate of the total score of TCM syndromes,the improvement rate of single TCM symptoms,and the analysis of automatic complete blood count.Compare with the historical literature,to analyze the difference between the efficacy of the spleen-tonifying and kidney-invigorating and the immunosuppressive therapy alone;through the stratification of efficacy to explore the correlation between the TCM syndrome classification,T cell immune response and clinical efficacy.Perform safety evaluation according to safety indicators.The research plan was approved by the ethics committee of Dongzhimen Hospital of Beijing University of Chinese Medicine(DZMEC-KY-2019-133).Initially explore the mechanism of applying spleen-tonifying and kidney-invigorating traditional Chinese medicine to regulate T cell immune response to treat CAA based on TCM syndrome classification of spleen deficiency and blood deficiency syndrome and kidney deficiency and blood deficiency syndrome.Results:1.CAA syndrome classification is associated with T cell subsets.The immune response disorder is more prominent in the spleen deficiency and blood deficiency group,the ratio of CD8+T cells and Treg cells is significantly higher than that in the kidney deficiency and blood deficiency group,and the ratio of CD4+/CD8+was further reduced compared with the kidney deficiency and blood deficiency group.?Cases of 57 patients with CAA were included,including 31 cases of spleen deficiency and blood deficiency syndrome and 26 cases of kidney deficiency and blood deficiency syndrome.There were 29 male patients and 28 female patients,with an average age of(54.38 ± 17.58)years.?Compared with the healthy group,the ratio of CD8+cells in the CAA group was significantly increased(P<0.05),and there was no significant difference in the ratio of CD3+,CD4+,Treg cells and CD4+/CD8+ratio(P>0.05).)Correlation analysis of TCM syndrome classification shows that the ratio of CD8+,Treg cells and CD4+/CD8+ ratio is associated with the TCM syndrome classification(P=0.010,P=0.046,P=0.025),the ratio of CD8+and Treg cells in the spleen deficiency and blood deficiency group are significantly higher than the kidney deficiency and blood deficiency group,the CD4+/CD8+ratio was significantly lower than the kidney deficiency and blood deficiency group.Binary logistic regression analysis showed that the ratio of CD8+cells is associated with the syndrome classification of TCM(OR=0.920,95%CI:0.860?0.985,P=0.017),the ratio of CD8+cells in the spleen deficiency and blood deficiency group were higher than the kidney deficiency and blood deficiency group.?32 patients whose T lymphocyte cell subsets were detected after 6 months of treatment were evaluated for efficacy,including 6 cases of remission,7 cases of obvious improvement,and 19 cases of ineffective.Compared with before treatment,the ratio of CD8+cells in the remission group was significantly reduced(P<0.05),the ineffective group was significantly increased(P<0.05),and there was no significant change in the obviously improved group(P>0.05);the CD4+/CD8+ratio in the ineffective group was further reduced(P<0.01).2.Taking spleen deficiency and blood deficiency and kidney deficiency and blood deficiency as the main types,the application of traditional Chinese medicine for spleen-tonifying and kidney-invigorating can helpf regulate T cell immune response to treat CAA.Among the effective patients,the ratio of activated T cells,CD3+HLA-DR+,CD8+HLA-DR+,CD4+HLA-DR+,CD8+HLA-DR+/CD8+,CD4+HLA-DR+/CD4+in the patients with spleen deficiency and blood deficiency after treatment were lower than that before treatment,but those in the patients with kidney deficiency and blood deficiency had no significant change.?Cases of 18 patients with CAA were included,16 were in the Full Analysis Set(FAS),and 14 were in the Per-Protocol Set(PPS).There were 7 cases in the spleen deficiency and blood deficiency group,and 9 cases in the kidney deficiency and blood deficiency group.?According to the judgment standard for clinical effect,the total effective rates of Fas and PPS were 62.5%and 71.4%respectively,which are basically consistent with the effective rates reported in foreign literature(35%-64%).The total effective rates of the spleen deficiency and blood deficiency group and the kidney deficiency and blood deficiency group were 71.4%and 55.6%respectively,and there was no statistical significance between the two groups(P>0.05).? According to the evaluation criteria of TCM syndromes,the improvement rates of syndromes of FAS and PPS were 87.5%and 92.9%respectively.The improvement rates of syndromes of the spleen deficiency and blood deficiency group and the kidney deficiency and blood deficiency group were 85.7%and 88.9%respectively,and there was no significant difference between the two groups(P>0.05).?Automatic complete blood count:In FAS,white blood cell count,neutrophil count and hemoglobin concentration were significantly increased after treatment(P<0.05,P<0.01).There were no significant differences in white blood cell count,neutrophil count,hemoglobin concentration,and platelet count between the spleen deficiency and blood deficiency group and the kidney deficiency and blood deficiency group before and after treatment(P>0.05).Before and after treatment within the group,the neutrophil count in the spleen deficiency and blood deficiency group were significantly increased after treatment(P<0.05),and the hemoglobin concentration in the kidney deficiency and blood deficiency group were significantly increased after treatment(P<0.05).? The total score of TCM syndromes:Compared with before treatment,the total score of TCM syndromes significantly decreased at 3 and 6 months of treatment in FAS(P<0.01).There was no significant difference between the spleen deficiency and blood deficiency group and the kidney deficiency and blood deficiency group at before treatment,at 3 months of treatment and at 6 months of treatment(P>0.05).Compared with before treatment,the total score of TCM syndromes significantly decreased at 3 and 6 months of treatment in the spleen deficiency and blood deficiency group and the kidney deficiency and blood deficiency group(P<0.01).?Single TCM symptom improvement rate:After 6 months of treatment,the single TCM symptom was improved compared with before treatment.The improvement rate of each TCM symptom was anorexia(86.7%),insomnia(83.3%),dry stool(80.0%),soreness and weakness of the lumbar region(78.6%),cold limbs(77.8%),night sweats(77.8%),physical and metal fatigue(73.3%),dizziness(69.2%),palpitate(66.7%),burning sensation of five centers(62.5%),loose stools(50.0%),bleeding(50.0%),pale complexion(46.7%).?T lymphocyte subsets and activation status:Compared with before treatment,there was no significant difference in the ratio of T lymphocyte subsets and activation status after treatment in FAS,and there was no significant difference between the spleen deficiency and blood deficiency group and the kidney deficiency and blood deficiency group after treatment(P>0.05).According to the judgment standard for clinical effect,there were 10 effective patients,including 5 patients with spleen deficiency and blood deficiency,and 5 patients with kidney deficiency and blood deficiency.Compared with before treatment,the ratio of CD3+HLA-DR+,CD8+HLA-DR+and CD8+HLA-DR+/CD8+were significantly reduced in effective patients after treatment(P<0.05),the ratio of activated T cells,CD3+HLA-DR+,CD4+HLA-DR+,CD8+HLA-DR+and CD8+HLA-DR+/CD8+,CD4+HLA-DR+/CD4+were significantly reduced in the spleen deficiency and blood deficiency patients after treatment(P<0.05),while the kidney deficiency and blood deficiency patients was no significant change(P>0.05).?Cytokines:FAS,spleen deficiency and blood deficiency group and kidney deficiency and blood deficiency group were not significantly different from before treatment,and there was no significant difference between the groups(P>0.05).? No serious adverse reactions occurred in all cases.Conclusion:Correlations are found between the classification of TCM syndromes of CAA and T cell immune response.The degree of dysregulation of immune response 'of spleen deficiency and kidney deficiency is different.Tonifying spleen and invigorating kidney may treat CAA by regulating T cell immune response.