Chinese Medicine Syndrome Analysis Of Primary Glomerulonephritis And Effects Of Sanqi Oral Solution To Tubulointerstitial Lesion

Objective:1. Try to classify the patients with Chronic glomerulonephritis accoding to diagnosis system using in tranditional chinese medicine.2. To investigate the Traditional Chinese Medicine Syndrome, clinicopathological characteristics and to probe into the relationship between prognosis and them of primary IgA nephropathy, the major pathological types of Glomerular diseases.3. This research will investigate protective effect of Sanqi Oral Solution which is composed according to principle of Strengthening-Qi and Activating blood on renal tubulointerstitial lesion and its mechanism in mesanginal proliferative glomerulonephritis rats.Method:1. With prospective and retrospective study, we observed 200 patients with chronic glomerulonephritis whose renal function were normal in the Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of TCM) from May 2005 to January 2010, through the syndrome of investigation and analysis of laboratory data to explore the distribution of their TCM characteristics and types of renal pathological.2.62 cases of IgA nephropathy proven by renal biopsy were retrieved from the Department of Nephrology, Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial hospital of TCM) from May 2005 to Jan 2010. Renal biopsies were reviewed, the clinical feature, laboratory data and pathological features were also studied retrospectively, and their prognosis were followed up which were divided into A clinical cure, B minor urinary abnormalities, C active nephropathy, D renal dysfunction as prognostic indicators of outcome.3. With extension of modeling time, the model of mesangial glomerulonephritis with tubulointerstitial lesion were replicated by injecting staphylococcal enterotoxin B (SEB) into rat caudal vein, feeding bovine serum albumin (BSA) administered every other day, subcutaneous injection Freund's adjuvant and BSA periocally. After 12 and 16 weeks of treatment of Sanqi Oral Solution, the pathological morphology were observed and 24 hours urine protein, urine microalbumin, NAG and CysC were detected. Through the application of immunohistochemistry, PCR, ELISA and other techniques, cytokines such as HGF, TGF-β1 and PAI-1 were detected also to explore its mechanism.Results:PartⅠ1. Syndromes of chronic nephritis cases:among of 200 cases,67 cases were male (33.5%) and 133 female (66.5%); the age was from 14 years to 77 years, the average age was 34.20±11.43 years. Chinese medicine syndromes included 123 cases of Qi deficiency (61.5%), Qi and Yin deficiency 50 cases (25.0%), Yin deficiency syndrome in 22 cases (11.0%),5 cases of Yang deficiency syndrome (2.5%). Damp-heat syndrome of TCM standed the first in the list, a total of 126 cases(63.0%), followed by 103 cases of blood stasis (51.5%), turbid damp in 22 cases (11.0%), water wet evidence in 10 cases (5.0 %), non-accompanied symptoms for the 27 cases (13.5%). The age-sex composition in patients of different TCM syndromes was not statistically significant.2. There were 135 cases of chronic nephritis proven in our hospital. Mesangial proliferative glomerulonephritis was the leading pathological type, including IgA nephropathy and non-IgA nephropathy mesangial proliferative glomerulonephritis.PartⅡ1. The 62 follow-up cases of IgA nephropathy included 15 males and 47 females. The age of initial onset was from 12 to 56 years and the average age of initial onset was 29.6±8.2 years. The age of biopsy was from 15 to 59 years, and the average age of biopsy was 31.4±8.0 years. The course between the onset of symptoms (or founding abnormal urine test) and the renal biopsy was from 6 days to 12 years, the average duration was 23.4±33.5 months. The initial presentation included urinary abnormalities in 30 patients (48.4 %), hematuria in 14 cases (22.6%), edema in 6 patients (9.7%), hypertension symptoms in 6 cases (9.7%), low back pain in 2 cases (3.2%), other manifestations in 4 cases (6.5%). Clinical outcomes were A (clinically cured) in 13 cases (21.0%), B (minor urinary abnormalities) in 37 (59.7 %), C (activate nephropathy) in 11 patients (17.7%), D (renal insufficiency) in 1 cases (1.6%), only one of them was end-stage renal disease who need hemodialysis.2. Follow-up duration was from 6 month to 4.5 years (mean follow-up duration:23.0±13.8months). There was no significant difference in outcome classification in different follow-up durations (P>0.05). There was no significant difference in outcome classification between different clinical types (P>0.05). Non-conditional Logistic regression analysis showed that there was no significant difference in sex, age of onset, age at renal biopsy, repeated gross hematuria and hypertension between clinical cure or mild urinary abnormalities group and activate nephropathy or renal insufficiency group. It confirmed that the degree of proteinuria was related to prognosis.3. Spearman rank correlation analysis showed that tubulointerstitial damage and glomerular injury was correlated (r=0.409, P=0.001). Hass histological type:there were 38.7%Ⅰgrade (24 cases),22.6%Ⅱgrade (14 cases),27.4%Ⅲgrade(17 cases),8.1%Ⅳgrade(5 cases),3.2%Ⅴgrade (2 cases). There were not correlated between prognosis and renal pathology Hass grade (r=0.160, P=0.215). Katafuchi semi-quantitative analysis showed that 83.9% patients (52/62 cases) associated with tubulointerstitial lesions (TIL), of which 45 cases (72.6%) had mild damage,6 cases (9.7 %), moderate damage,1 patients (1.6%), severe damage. Prognosis and the degree of tubulointerstitial lesions were not correlated (r=0.136, P=0.294). There was significant difference between patients in prognosis with or without vascular wall thickening (P<0.01).4. Qi deficiency is most common type of TCM Syndrome, accounting for 40 cases (64.5%). Qi and Yin deficiency, Yang deficiency syndrome and Yin deficiency syndrome accounted for 11 cases (17.7%),2 cases (3.2%) and 9 cases (3.2%), respectively. There was no significant difference between TCM Syndromes in prognosis (P>0.05).PartⅢ1.24 hours urine protein of rat models increased in 10 weeks and 16 weeks compared with the normal group. After treatment,24-hour urine protein decreased in Sanqi Oral Solution group, benazepril group and model group, but the difference was not statistically significant. In 10 weeks and 16 weeks, the urinary microalbumin, NAG activity and CysC in rat models were increased, compared with the normal group. After treatment, such laboratorial parameters in Sanqi Oral Solution group, benazepril group decreased, compared with model group and The difference was statistically significant. And there was no significant difference between the Sanqi Oral Solution group and benazepril group. In 16 weeks, serum creatinine in control group was higher than other groups and there was no significant difference in urea level between groups.2. After treatment for 16 week, PAI-1 levels in renal tissue of model rats were increased, compared with the normal group and the difference was statistically significant. PAI-1 levels in Sanqi Oral Solution group, benazepril group decreased significantly compared with model group. Q-RT-PCR showed that TGFβ1mRNA expression in the model rats was 1.12 times than the normal control group, in benazepril group and Sanqi Oral Solution group it was 1.05 times and 0.93 times respectively. The expression of HGF mRNA in Model group was 0.82 times than the normal control group, in benazepril group and Sanqi Oral Solution group it was 1.33 times and 1.20 times respectively. Immunohistochemical analysis showed that a small amount expression of TGF-β1 was observed in normal renal tissue. After treatment compared with the normal control group, TGF-β1 expression in renal tissue of model group was significantly higher (P<0.01). Compared with model group, expression of TGF-β1 was significantly lower in Sanqi Oral Solution group (P<0.05) and it decreased also in benazepril group but the difference was not statistically significant (P>0.05). A small amount expression of HGF was observed in normal renal tissue. In the model group expression of HGF increased, but the difference was not significant (P> 0.05). After treatment in Sanqi Oral Solution group and benazepril group HGF expression were increased (P<0.05). Conclusions:1. Patients with chronic nephritis, whose renal function were normal, were generally relatively young, and women were more common. TCM syndrome had nothing to do with age-sex. In deficiency syndrome, Qi deficiency and Qi and Yin deficiency were more common, whereas Yang deficiency was rare. In excess syndrome, damp-heat and blood stasis were dominant. Mesangial proliferative glomerulonephritis was the leading pathological type, including IgA nephropathy and non-IgA nephropathy mesangial proliferative glomerulonephritis.2.2.1 Among 62 follow-up cases of IgA nephropathy, urinary abnormalities was dominated in the initial presentation and clinical type. Prognosis had nothing to do with follow-up period, clinical type, gender, age of onset, age at renal biopsy, repeated gross hematuria, course of disease and high blood pressure, but was related to the degree of proteinuria at biopsy.2.2 glomerular damage and tubulointerstitial lesion had a very good correlation in IgA nephropathy patients. Renal vascular damage affected survival prognosis.2.3 This is the first study of TCM syndromes on the follow-up prognosis. In theory, with Yang deficiency, Yin deficiency, Qi and Yin deficiency it was worse than qi deficiency, and treatment may be more poor. But we did not find this law. Damp-heat and blood stasis had not shown worser prognosis than non-damp-heat and non-blood stasis syndrome. While the sample size in this group may be smaller or the duration may be shorter, on the other hand may also illustrate the syndrome differentiation therapy achieving the same to their best individual treatment, suggesting the importance of TCM Differential Diagnosis and Treatment.3. The results showed that Chinese compound formula Sanqi Oral Solution can reduce the rat urinary albumin, NAG activity, CysC level; reduce PAI-1 levels in renal tissue, increase expression of renal hepatocyte growth factor (HGF) and decrease expression of TGFβ1, which may be one of the mechanisms of protection of renal tubular function.