Clinical And Mechanism Study Of Rhubarb’s Compound Prescription And Its Effective Components In Treating Chronic Renal Failure

The evidence-based medicine evidence for rhubarb on the treatment of chronic renal failureObjective:To evaluate the effectiveness and safety of rhubarb on treating chronic renal failure (CRF).Method:All randomized or semi-randomized controlled trials (RCTs or semi-RCTs) of rhubarb in treating CRF were collected from CBM, CNKI, VIP, WanFang, EMBASE, MEDLINE, PUBMED and Cochrane library clinical controlled trials database. After two researchers for screening and data extraction independently, the quality of the included literature research was evaluated according to the modified Jadad rating scale, then Revman 5.3 software was used to undertake meta analysis.Results:(一) The efficacy of rhubarb or rhubarb compound prescription oral on chronic renal failure:a Meta-analysisA total of 35 RCTs and semi-RCTs were obtained, including 3060 patients, treatment group 1657 patients vs control group 1403 patients. Meta analysis indicated that rhubarb or rhubarb compound prescription oral treatment gave better results in lowering Serum creatinine (Scr) [MD=-73.28,95%CI(-85.96,-60.60)] and blood urea nitrogen (BUN) [MD=-2.47,95%CI (-3.13,-1.82)], increasing endogenous creatinine clearance rate (Ccr) [MD= 6.66,95%CI (2.93,10.40)], as well as increasing hemoglobin (Hb) [MD= 9.31,95%CI (3.81,14.80)] and serum albumin (Alb) [MD= 2.94,95%CI(1.75,4.13)], and also lowering 24 h urinary protein (24 h UTP)[MD=-0.63,95%CI(-0.95,-0.30)], triglycerides (TG) [MD=-0.53, 95%CI (-0.73,-0.32)] and cholesterol (TC)[MD=-1.01,95%CI(-1.44,-0.58)], In addition, it can improve total efficiency of the symptoms and signs in patients with CRF[Peto OR= 3.42,95%CI (2.84,4.12)]. But there is no statistically significant for reducing the incidence of ESRD [Peto OR= 0.57,95%CI(0.19,1.75)] compared with control therapy alone.(二)The efficacy of rhubarb enema on chronic renal failure:a Meta-analysisA total of 28 RCTs and semi-RCTs were obtained, including 2278 patients, treatment group 1220 patients vs control group 1058 patients. Meta analysis indicated that rhubarb enema treatment gave better results in lowering Serum creatinine (Scr) [MD=-59.62,95%CI (-88.58,-30.67)] and blood urea nitrogen (BUN) [MD=-3.27,95%CI (- 4.49, -2.05)], increasing endogenous creatinine clearance rate (Ccr) [MD= 3.95,95%CI (-0.03,7.93)], improving total efficiency of the symptoms and signs in patients with CRF[Peto OR= 4.08,95%CI (3.25,5.12)], as well as improving the main symptom of anorexia [MD=-0.48,95%CI (-0.77,-0.19)], nausea and vomiting [MD=-0.65,95%CI (-0.78,-0.52)]. But there is no statistically significant for increasing hemoglobin (Hb) [MD= 6.85,95%CI (- 1.82, 15.52)] and reducing uric acid (UA) [MD=-46.84,95%CI (-102.91,9.22)] compared with control therapy alone.Conclusion:Rhubarb or rhubarb compound prescription oral and rhubarb enema significantly reduced Scr, BUN, increased Ccr, and improved total efficiency of the symptoms and signs in patients with CRF, rhubarb or rhubarb compound prescription oral can increase Hb, Alb, reduce 24 h UTP, TG and TC, however, there is no evidence for reducing the incidence of ESRD is more effective than control group. In addition, rhubarb enema significantly improving the main symptom of anorexia, nausea and vomiting, however, there is no evidence for increasing Hb and reducing UA is more effective than control group in CRF treatment, indicating that rhubarb may be a relatively safe and effective drug for treatment of CRF. Due to low quality of the methodological of included studies, pending further high-quality researches to study its efficacy and safety.Emodin ameliorates renal tubular cell injury through activation of autophagyBackground and objectivesCurrently, chronic kidney disease (CKD) has become a common and frequently-occurring disease, which has a great harm to public health. Nephrotoxic drug-induced acute renal failure has become the focus attention of clinicians, Cisplatin (CDDP) is a broad spectrum, effective chemotherapy drugs, which used to treat a variety of malignant tumors in clinical. However, according to clinical statistics, the incidence of kidney damage was 25%-35% after cisplatin chemotherapy. And the increased renal toxicity caused by CDDP is also greatly increased along with the dosage, which has become a major factor limiting the amount and expanding the scope of application of CDDP. Western medicine may caused excessive adverse reactions when used in the treatment of drug-induced nephrotoxiciry. Therefore, looking for the Chinese medicine not only have the efficacy of reducing nephrotoxicity caused by CDDP, but also could retain its anticancer activity, has become a research focus over the years by many scholars.Autophagy is a lysosomal-dependent macromolecular proteins and organelles degradation process by eliminating senescent cells and long-lived proteins, providing raw materials and nutrients to the cellular repair, ultimately to achieve organelle update. Apoptosis is a special, regulated by genes, biological autonomous programmed cell death manner, which can remove non-body desired cell, maintain a stable number of cells. Nephrotoxic drugs can cause renal tubular epithelial cell apoptosis, an increasing number of studies have reported autophagy plays an important role in renal tubular epithelial cell apoptosis induced by CDDP, autophagy occurs prior to apoptosis, it may become its anti-apoptotic mechanism.Emodin is an anthraquinone derivatives, is the main active ingredient of rhubarb, a large number of studies have shown that emodin has renal protective effects, mainly in the anti-inflammatory, inhibiting proliferation, inhibition of cell phenotypic change, as well as antioxidant and so on. Emodin has been reported to improve renal toxicity related to CDDP, however, it has not yet been reported whether emodin can improve CDDP-induced renal injury by autophagy pathway. But studies have reported that emodin is an efficient adenosine monophosphate (AMP) activated protein kinase (AMPK) activators, and can regulate the mammalian target of rapamycin (mTOR) pathway. Since AMPK/mTOR signal pathway plays an important role in the regulation of autophagy, therefore, we hypothesized that in CDDP-induced renal injury, whether it is a possible that emodin plays an important role in protecting cell damage by regulating autophagy.We selected renal tubular epithelial cells (NRK-52E cells) and established CDDP-induced cell damage model in vitro, observing the effect of emodin on CDDP-induced changes in autophagy related proteins, autophagosome formation, and autophagy-related signaling pathways. Exploring the changes of autophagy in nephrotoxicity renal injury and the intervention effect of emodin, then evaluated the protective effects of emodin on CDDP-induced cellular apoptosis in NRK-52E cells, and explored the potential mechanisms, providing a new target for clinical application emodin.MethodsFirstly, changes of cell morphology and the expression of apoptosis-related markers were observed after the treatment of cisplatin. Then NRK-52E cells were treated with cisplatin with or without emodin, microscopic analysis was performed, as well as the expression of the abundance of cleaved Caspase-3 and microtubule-associated protein 1 light chain 3 (LC3) I/II, which was autophagy marker protein of mammalian congeners, were detected by western blot. Redfluorescent protein-LC3 (RFP-LC3) plasmid was transiently transfected into NRK-52E cells, after the intervening of emodin, changes of RFP-LC3 fluorescent particles were observed by fluorescence microscopy.Secondly, bafilomycin Al, which can inhibit autophagosome-lysosome fusion, was applied as an autophagic inhibitor in this study. Additionally, NRK-52E cells were treated with mammalian target of rapamycin mTOR inhibitor rapamycin, the level of LC3 was examined by western blot, morphological changes of apoptotic cells were observed under the microscope and cisplatin-induced cell death were further evaluated by Annexin V and PI assay.Thirdly, further testing effects of emodin on activation of autophagy via regulating the AMPK/mTOR signaling pathway. The AMPK/mTOR signaling pathway related proteins were detected after the treatment of emodin by western blot. At the same time, the changes of NRK-52E cells morphology and the expression of Caspase-3 and cleaved Caspase-3 were detected after the addition of compound C, which is a well-known AMPK inhibitor. In addition to the above pathway, we also observed the MAPKs family, including ERK, P38 and JNK signaling pathway, to explore whether these pathways are also involved in the autophagy activation induced by emodin.Finally, after the treatment of emodin at different time points, we detected the expression of p-ERK, p-p38 and p-JNK proteins, as well as LC3-I and LC3-II proteins by western blot. At the same time, we also use emodin with or without ERK inhibitor PD098059 or p38 inhibitor SB203580 treated cells, and then observed the expression of p-ERK and p-p38 proteins.Results(1) After the treatment of CDDP, with the time prolonged and dosage increased, apoptotic cells was observed under the microscope. Western Blot results showed that early autophagic related proteins (LC3-I and LC3-II) expression were increased, the ratio of LC3-II/LC3-I was increased, later, the expression of apoptosis-related protein (cleaved Caspase-3) was increased. CCK-8 assay and flow cytometry results consistent with the results of western blot.(2) CDDP can reduce the number of viable cells, after emodin intervention, the number of surviving cells was significantly increased. Western blot showed that cells were cotreatment with emodin and CDDP can significantly reverse the raised expression of cleaved Caspase-3 protein treated with CDDP alone. Simultaneously, treatment with emodin can significantly increase the ratio of LC3-II/I and the expression of GFP-LC3 punctate structures. We selected rapamycin treated cells, and also observed that it can increased expression of LC3-I and LC3-II, as well as the ratio of LC3-II/LC3-I, under the microscope, the protective effects of emodin can also be abolished by bafilomycin Al. In addition, emodin can also significantly decrease the expression of p-p70S6K and p-mTOR proteins, upregulate the expression of p-AMPK protein in a time-dependent manner. Western blot showed that compound C, an AMPK inhibitor, can significantly inhibit emodin-induced phosphorylation of AMPK, as well as the conversion of LC3-I to LC3-II. The results of fluorescence microscopy were consistent with western blot, when added compound C, red fluorescent particles induced by emodin were significantly reduced. Observed under the inverted microscope also found that compound C can significantly inhibit anti-apoptotic effect of emodin, western blot also showed that emodin can significantly decrease the expression of cleaved Caspase-3 protein induced by CDDP, but when added compound C, the expression of cleaved Caspase-3 protein was significantly increased.(3) Western blot showed that the expression levels of p-ERK, p-p38 and p-JNK proteins were increased in the early stage and decreased later, when the addition of ERK inhibitor PD098059 and p38 inhibitor SB203580, the increased p-ERK and p-p38 proteins were significantly suppressed.ConclusionsOur study found that autophagy is appear in the early stage after the treatment with CDDP in NRK-52E cells, later is apoptosis. Induction of autophagy could be an important mechanism by which emodin protected renal tubular cells against CDDP-induced cell injury, and the potentially mechanism of emodin-induced autophagy may be attributed to the activation of AMPK and inhibiting mTOR signaling pathway, as well as MAPKs family-mediated signaling pathways. Emodin may have a therapeutic potential in the prevention of cisplatin-induced nephrotoxicity.Clinical efficacy of rhubarb’s compound prescription, invigorating kidney and clearing, detoxicating and puging tubid methods, delaying progression of chronic renal failureObjective:To evaluate the clinical efficacy of rhubarb’s compound prescription, invigorating kidney and clearing, detoxicating and puging tubid methods for delaying the progression of chronic renal failure.Methods:In this study, we adopt a retrospective study, selecting 51 patients diagnosed with chronic renal failure from Nephropathy Department of Jiangsu Province Hospital of TCM, and who were treated for 2 years by the method of invigorating kidney and clearing, detoxicating and puging tubid methods as well as adding and subtracting rhubarb, and then observing the changes in clinical symptoms and clinical efficacy indicators before and after treatment.Results:After 24 months treatment of invigorating kidney and clearing, detoxicating and puging tubid methods as well as adding and subtracting rhubarb, the total points of Traditional Chinese medicine clinical symptoms of 51 patients has significantly decreased (P< 0.01). After treatment, the primary efficacy endpoints of the patient, such as Scr, BUN, UA were significantly decreased, the difference was statistically significant (P< 0.01). Other indicators, the RBC has increased, the difference was statistically significant (P< 0.01), Hb increased slightly, but the difference was no statistical significance (P> 0.05); comparison of TC before and after treatment, the difference was statistically significant (P< 0.01); after treatment, there was a slight decline in TG, but no significant difference (P> 0.05).Conclusion:Invigorating kidney and clearing, detoxicating and puging tubid methods as well as adding and subtracting rhubarb could significantly reduce the clinical symptoms, stabilize and improve renal function in patients, different degrees lower Scr, BUN, UA, lipid levels, to a certain extent, anemia have also been improved, indicating that the method has exact clinical efficacy in improving the patient’s quality of life and delaying the progress of renal function.