| Purpose: 1.To summarize the theoretical basis and prescription ideas of Professor 高 天 舒 ’s application of tonifying spleen and kidney and dredging collateralsin the treatment of G1A2 Diabetic Kidney Disease(DKD).2.Meta-analysis was used to verify the efficacy and safety of tonifying spleen and kidney and dredging collaterals in the treatment of DKD.3.To observe the clinical efficacy of tonifying spleen and kidney and dredging collaterals in the treatment of G1A2 DKD patients with spleen-kidney deficiency and collateral-vein stasis syndrome,To provide an objective experimental basis for the treatment of DKD with traditional Chinese medicine.4.To study the effect of tonifying spleen and kidney and dredging collateralson hyperfiltration,glomerular function,renal tubular function and pathological morphology of Diabetes Mellitus(DM)rats.5.To explore whether tonifying spleen and kidney and dredging collateralsaffect renal hyperfiltration in DM rats through Tubuloglomerular feedback mechanism.Material and method:1 Professor Gao tianshu’s academic thoughts on the treatment of G1A2 DKD with the method of "tonifying spleen and kidney and dredging collaterals"Professor Gao tianshu’s treatment concept of DKD using tonifying spleen and kidney and dredging collaterals is explained from the aspects of etiology,pathogenesis,treatment principles,and analysis of prescription.2 Meta-analysis of the efficacy and safety of tonifying spleen and kidney and dredging collaterals in the treatment of G1A2 DKDPubmed database,Embase database,Cochrane Controlled Trial Center database,China National Knowledge Infrastructure(CNKI),Wanfang Data Knowledge Service Platform,China Biology Medicine Disc,VIP Chinese Science and Technology Journal Database were used to search literature from the time of database establishment to June 2022.The literature was screened strictly according to the inclusion and exclusion criteria.The control group was treated with conventional western medicine,and the experimental group was treated with tonifying spleen and kidney and dredging collaterals on the basis of the control group.Literature quality was evaluated and literature data were extracted.Finally,Rev Man 5.3 software was used for statistical analysis.3 Clinical study of tonifying spleen and kidney and dredging collaterals in the treatment of G1A2 DKDA total of 106 patients who were diagnosed with G1A2 DKD in the Department of Endocrinology and Affiliated Hospital of Liaoning University of Traditional Chinese Medicine from December 2019 to November 2021 were randomly divided into a treatment group and a control group,with 53 cases in each group.The control group was treated with conventional basic treatment of western medicine,and the treatment group was treated with Bupi-Yishen-Tongluo decoction on the basis of the control group.After 12 weeks of treatment,the urinary microalbumin/creatinine ratio(UACR),urinaryα1-microglobulin(α1-MG),urinary β2-microglobulin(β2-MG),N-acetyl-β-D glucosaminidase(NAG),urinary retinol binding protein(RBP),renal function,glycosylated hemoglobin(Hb A1c),fasting blood glucose(FBG),2-hour postprandial blood glucose(2h PBG),blood lipids,TCM syndrome score,effective rate,and the Quality of Life with Diabetes Specific Quality of Life Scale(DSQL)score,and safety indicators were compared between the two groups before and after treatment.Data information were statistically analyzed by SPSS 22.4 Effect of tonifying spleen and kidney and dredging collaterals on the function of glomerular、renal tubular and morphology in DM ratsAfter adaptive feeding for 1 week,25 male SD rats were randomly selected as the normal group(N group).The remaining 75 rats were fed with high-sugar and high-fat diet for 4 weeks,and then combined with low-dose streptozotocin(STZ)(42 mg·kg-1)by intraperitoneal injection to establish diabetes mellitus(DM)model.Then the DM rats were randomly divided into model group(group M),Bupi-Yishen-Tongluo group(group P)and losartan group(group L).Bupi-yishen-tongluo Decoction(23.4 g·kg-1)was given by gavage in group P,losartan tablets(9 mg·kg-1)was given by gavage in group L,and the equal volume of distilled water was given by gavage in N and M groups for 11 weeks.Rat 24-hour urine was collected using metabolic cages for indicator detection.Tail tip random blood glucose and body weight were measured every 2 weeks,and samples were collected at the end of the 6th and 11 th weeks for index detection.Enzyme-linked immunosorbent assay(ELISA)was used to detect 24 h urinary microalbumin quantification(UAER),urineα1-MG,β 2-MG,RBP,NAG,urine creatinine,serum creatinine and blood urea nitrogen.Hematoxylin-eosin(HE)staining,glycogen staining(PAS)and Masson staining(Masson)were performed to observe the pathological changes of the kidney,and the glomerular volume was calculated based on the results of HE staining.5 To study the effect of tonifying spleen and kidney and dredging collaterals on DM hyperfiltration based on the Tubuloglomerular feedback mechanismThe methods of feeding and sampling of experimental animals were the same as those in Part 4.Renal sodium-glucose cotransporter 1(SGLT1),sodium-glucose cotransporter 2(SGLT2),sodium-potassium-chloride cotransporter 2(NKCC2),gap junction protein 40(Cx40),mitogen-activated protein kinase P38(P38mapk)and cyclooxygenase 2(Cox2)were detected by immunohistochemistry(IHC).Immunofluorescence(IF)was used to observe the localization of adenosine type 1 receptor(A1AR)and Renin in kidney.The expressions of SGLT1,SGLT2,NKCC2,Cx40,A1 AR,P38mapk,Cox2 and Renin in kidney tissue were detected by Western blot and real-time fluorescence quantitative polymerase chain reaction(Real-time PCR).Results:1 Professor Gao tianshu’s academic thoughts on the treatment of G1A2 DKD with the method of "tonifying spleen and kidney and dredging collaterals"Professor Gao tianshu believes that the basic pathogenesis of G1A2 DKD is spleen and kidney qi deficiency and kidney collateral stasis,and the basic treatment principle is to tonifying spleen and kidney and dredging collaterals.According to the principles of treatment,the composition of tonifying spleen and kidney and dredging collaterals decoction consists of prepared Rehmannia root、Dogwood、Dodder、Polygonatum、Radix Dipsaci tonifying kidney and filling essence,Astragalus、ginseng、yam Yiqi Jianpi,Leech,earthworm,Panax notoginseng Tongluo and so on.Attention should be paid to the addition and subtraction of the syndrome,the adjustment of external sensation,diet,emotion,work and rest,and the combination of health care and treatment is conducive to delaying the progression of the disease.2 Meta-analysis of the efficacy and safety of tonifying spleen and kidney and dredging collaterals in the treatment of G1A2 DKDA total of 244 articles were retrieved by searching various databases.After excluding duplicate literature and literature that did not meet the requirements,22 literatures were finally included in the Meta-analysis,and the results were as follows.(1)Blood glucose: The levels of FBG,2h PBG and Hb A1 c in the experimental group were lower than those in the control group,respectively[MD=-0.51,95%CI[-0.7,-0.31],Z=4.96,P<0.01],[MD=-0.61,95%CI[-0.96,-0.26],Z=3.38,P<0.01],[MD=-0.14,95%CI[-0.19,-0.08],Z=4.9,P<0.01].(2)Levels of urinary protein and renal function: The 24-hour urinary protein,urinary albumin excretion rate,urinary microalbumin and urea nitrogen in the experimental group were lower than those in the control group,and the results were[MD=-0.24,95%CI[-0.37,-0.11],Z=3.6,P<0.01],[MD=-35.91,95%CI[-51.61-20.21],Z=4.48,P<0.01],[MD=-12.94,95%CI[-23.57,-2.30],Z=2.38,P<0.05],[MD=-1.82,95%CI[-3.55,-0.08],Z=2.05,P<0.05].There was no significant difference in serum creatinine between the experimental group and the control group.(3)Blood lipid levels: Compared with the control group,the improvement of TC,TG and LDL-C in the experimental group was statistically significant [MD=-0.74,95%CI[-1.04,-0.45],Z=5.0,P<0.01],[MD=-0.38,95%CI[-0.51,-0.24],Z=5.42,P<0.01],[MD=0.32,95%CI[-0.51,-0.13],Z=3.36,P<0.01].and the difference was statistically significant.There was no significant difference in HDL-C between the experimental group and the control group [MD=0.09,95%CI[-0.07,0.25],Z=1.13,P=0.26>0.05].(4)Efficiency: The effective rate of western medicine in the experimental group was higher than that in the control group [relative Risk Ratio(RR)=4.23,95%CI[2.95,6.05],Z=7.88,P<0.01],and the effective rate of TCM syndrome was higher than that in the control group [RR=4.39,95%CI[2.62,7.36],Z=5.6,P<0.01].(5)Others: Compared with the control group,the improvement of cystatin-C and fibrinogen in the experimental group was statistically significant [MD=-0.27,95%CI[-0.4,-0.15],Z=4.22,P<0.01],[MD=-0.82,95%CI[-1.18,-0.46],Z=4.5,P<0.01].(6)Three articles reported mild adverse reactions,and the rest stated that no adverse reactions occurred.3 Clinical study of tonifying spleen and kidney and dredging collaterals in the treatment of G1A2 DKD(1)There were no significant differences in all indexes between the two groups before treatment(P >0.05),which were comparable.(2)Comparison of blood glucose: after treatment,Hb A1 c,FBG and 2h PBG in the two groups were significantly lower than those before treatment(P<0.01).Compared with the control group,the treatment group decreased more significantly(P<0.05).(3)Urinary protein comparison: compared with before treatment,the levels of UACR,α1-MG,β2-MG,NAG and RBP in the two groups after treatment were significantly decreased(all P<0.01).After treatment,UACR,β2-MG,NAG and RBP in the treatment group were lower than those in the control group(P<0.05).(4)Blood lipid levels: compared with before treatment,the total cholesterol(TC),triglyceride(TG),high-density lipoprotein(HDL-C)and low-density lipoprotein(LDL-C)of the two groups after treatment were decreased(P<0.05).Compared with the control group,TC and TG in the treatment group were decreased(P<0.05).(5)Renal function: urea nitrogen,serum creatinine,and estimated glomerular filtration rate of the two groups were within the normal range before and after treatment.(6)Blood pressure and BMI: after treatment,the blood pressure and BMI levels of the two groups decreased(P < 0.05),and there was no significant difference between the two groups.(7)DSQL score: compared with before treatment,the scores of physiological function,psychological spirit,social relationship and treatment dimensions of the two groups after treatment were significantly decreased(all P<0.01).After treatment,the improvement of physiological function,psychological spirit and social relationship in the treatment group was better than that in the control group(all P<0.05).(8)TCM syndrome score: compared before treatment,the TCM syndrome score and single symptom score after treatment were decreased in the two groups(P<0.01,P<0.05).After treatment,the TCM syndrome score and single symptom score in the treatment group were better than those in the control group(all P<0.05).(9)The total effective rate of the control group was 68.62%,the significant effective rate was 35.29%,and the treatment group was 82.69%,48.07%,respectively.The total effective rate and significant efficiency of the treatment group were better than those of the control group(P<0.05).(10)The safety indicators of patients in the two groups were normal after treatment,and no adverse reactions occurred.4 Effect of tonifying spleen and kidney and dredging collaterals on the function of glomerular、renal tubular and morphology in DM rats(1)Compared with the N group,the blood glucose values of the other groups were significantly increased at each time point(P<0.01).At 6 weeks,compared with the M group,the P group decreased(P<0.05),and there was no significant change in the L group.At 10 and 11 weeks,compared with group M,P and L groups decreased significantly(P<0.05),compared with group L,P group decreased significantly(P<0.05,P<0.01).(2)The body weight of rats: compared with N group,the body weight of other groups decreased significantly at 6 weeks(P<0.01).Compared with group M,there was no change in group P(P>0.05),and it was decreased in group L(P<0.05).At 11 weeks,compared with N group,the body weight of other groups decreased significantly(P<0.01).Compared with group M,P and L groups were significantly increased(P<0.05).(3)Renal coefficient: Compared with the N group,the renal coefficient of the 6 weeks and 11 weeks in M groups were significantly increased(both P<0.01).Compared with group M,the kidney coefficient in group P decreased at 6 and 11 weeks(P<0.05).(4)Endogenous creatinine clearance rate(Ccr): compared with N group,Ccr in M group was significantly increased at 6 and 11 weeks(both P<0.01).Compared with the M group,Ccr in the P and L groups decreased significantly at 11 weeks(both P<0.01).Compared with group L,Ccr was significantly decreased in group P at 11 weeks(P<0.01).(5)UAER:Compared with N group,M group were significantly increased at 6 and 11 weeks(P<0.01).Compared with group M,P group decreased after 6 weeks(P<0.01),and P and L groups decreased significantly after 11 weeks(P<0.01).Compared with L group,P group decreased at 11 weeks(P<0.05).(6)α1-MG,β2-MG,RBP and NAG: compared with the N group,the four proteins in the M group were significantly increased(all P<0.01).Compared with the M group,the four proteins in the P group were significantly decreased(all P<0.01).(7)Pathological staining: compared with the N group,the glomerular volume was increased,the basement membrane was thickened,and the renal tubular epithelial cells were shed in the M group.Compared with the M group,the renal pathology of the P group was improved.(8)Glomerular volume: compared with N group,the glomerular volume of M group was increased P<0.01).Compared with group M,the glomerular volume was significantly decreased in groups P and L(P<0.01).5 To study the effect of tonifying spleen and kidney and dredging collaterals on DM hyperfiltration based on the Tubuloglomerular feedback mechanism(1)Expression of A1 AR pathway related factors:(1)IHC and IF observation localization: renal SGLT1 and SGLT2 were localized in proximal tubules,NKCC2 was localized in macula densa,Cx40 was mainly expressed around arteries,and A1 AR was expressed in glomerular arterioles.(2)WB: SGLT1,SGLT2: compared with group N,the expressions of SGLT1 and SGLT2 in group M were significantly increased at 6 and 11 weeks,and increased with time(P<0.05).Compared with group M,the expressions of SGLT1 and SGLT2 in P and L groups were decreased to different degrees,which were statistically significant.NKCC2:At 6 weeks,compared with group N,group M was significantly increased(P<0.01),and compared with group M,groups P and L were significantly increased(P<0.01);At 11 weeks,there was no significant change in group M compared with group N.Compared with group M,the expressions of P and L groups were significantly increased(all P<0.01).Compared with 6 weeks node,the expression of M group was down-regulated at 11 weeks(P<0.01).Cx40: At 6 weeks,compared with group N,the Cx40 in group M was significantly increased(P<0.01),and compared with group M,the Cx40 in group L was decreased(P<0.05).At 11 weeks,M group was significantly higher than N group(P<0.01).Compared with group M,the expression of the two treatment groups was significantly increased(all P<0.01).Compared with the 6-week node ratio,the M group was down-regulated at 11 weeks(P<0.05).A1AR: At 6 weeks,there was no significant difference in the ratio between groups.At 11 weeks,compared with group N,the expression of A1 AR in group M was significantly decreased(P<0.01).Compared with group M,P and L groups were significantly increased(P<0.01).(3)RT-q PCR: SGLT1 m RNA: There was no significant difference in the expression of SGLT1 m RNA in each group at 6 weeks,but was upregulated in group M compared with group N at 11 weeks(P<0.01).Compared with group M,group L was down-regulated(P<0.05).SGLT2 m RNA: At 6 weeks,compared with group N,the expression of SGLT2 m RNA in M group was increased(P<0.05).At 11 weeks,compared with group N,the expression of group M was increased(P<0.01),and compared with group M,the expression of group P was decreased(P<0.05).NKCC2 m RNA: At 6 weeks,compared with group N,group P was up-regulated(P<0.05).At 11 weeks,compared with N group,P and L groups were significantly increased(all P<0.01),compared with M group,P and L groups were significantly increased(all P<0.01).After 6 weeks and 11 weeks,the decrease in group M was statistically significant(P<0.05).Cx40 m RNA: There was no significant difference in the expression of Cx40 m RNA in each group at 6 weeks.At 11 weeks,compared with N,the expressions of P and L groups were increased,and compared with M group,P and L were increased(P<0.05).Compared with 6 weeks,11 weeks,the M group was down-regulated,while the P and L groups were increased,with statistical significance.A1 AR m RNA: at 6 and 11 weeks,there was no significant change in group M compared with group N,but increased in group P compared with group M(P<0.05).(2)Expression of Renin pathway related factors:(1)IHC and IF observation localization: P38mapk: mainly expressed in macula densa and proximal renal tubules;Cox2: mainly expressed in proximal renal tubules;Renin was mainly expressed in granulosa cells of paragglomerular apparatus and glomerular arterioles.(2)WB: P38mapk: At 6 weeks,there was no significant change in group M compared with group N.Compared with group M,P and L groups were significantly increased(P < 0.05).At 11 weeks,compared with group N,group M was significantly up-regulated((P<0.01).Compared with group M,P and L groups were significantly down-regulated(P<0.01).Compared with the node at 6 weeks,the down-regulation in group P at 11 weeks was statistically significant(P<0.05).Cox2:At 6 weeks,compared with group N,group M increased(P<0.05),compared with group M,group L decreased(P<0.05).At 11 weeks,compared with group N,group M was up-regulated(P<0.01).Compared with group M,the expressions of P and L groups were significantly down-regulated(all P<0.01).Compared with the nodes at week 6,the nodes in group M were up-regulated at week 11(P<0.01),and the nodes in groups P and L were down-regulated at week 11(all P<0.05).Renin: At 6 weeks,compared with group N,the other groups were increased(P<0.01),compared with group M,the L group was increased(P<0.01).At 11 weeks,compared with group N,group M was significantly up-regulated(P<0.01).Compared with group M,the expression of P and L was down-regulated(all P<0.01).Compared with the node of 6 weeks,the expression of M group was up-regulated and L group was down-regulated at 11 weeks(all P<0.01).(3)P38mapk m RNA: At 6 weeks,compared with group N,group M was significantly increased(P<0.01).At 11 weeks,compared with group N,group M was significantly higher(P<0.05).Compared with group M,group P was decreased(P<0.05).Cox2 m RNA: At 6 weeks,there was no significant difference between groups.At 11 weeks,M group was significantly higher than N group(P<0.01).Compared with group M,P and L groups were decreased(P<0.05).Renin m RNA: At 6 weeks,the expression of Renin in group M was significantly up-regulated compared with that in group N(P<0.01).At 11 weeks,compared with group N,the expression in group M was significantly up-regulated(P<0.01),and compared with group M,the expression in groups P and L was significantly decreased(P<0.01).Conclusion:1.Professor Gao Tian-shu believes that stage G1A2 DKD belongs to the category of "subtle discharge".Deficiency of kidney essence is the root cause of DKD,and deficiency of spleen is the contributing factor.It is often accompanied by microscopic lump pathological product of the renal collateral.It is proposed that tonifying kidney and filling essence,invigorating spleen and qi are the first essentials of treatment,and promoting collaterals and blood circulation throughout the treatment.Commonly used drugs include prepared Rehmannia root,Dogwood,Dodder,Polygonatum,Radix Dipsaci tonifying kidney and filling essence,Astragalus,ginseng,yam to invigorate qi and invigorate spleen,leech,lumbricus,Panax notoginseng,turtle shell,raw oyster,etc,to promote blood circulation,disperse knot and eliminate diseases.Flexible addition and subtraction with the syndrome,pay attention to lifestyle adjustment.2.The treatment of G1A2 DKD by tonifying spleen and kidney and dredging collaterals can reduce UACR,α1-mg,β2-mg,NAG,RBP levels and blood glucose,regulate blood lipids and delay the progression of renal function.Secondly,it can alleviate the TCM symptoms of spleen and kidney deficiency and collateral-vein stasis syndrome in G1A2 DKD and improve DSQL score,which shows that the quality of life of patients is improved.3.Tonifying spleen and kidney and dredging collaterals can reduce glomerular function and renal tubular function injury,and improve renal hypertrophy and hyperfiltration in DM rats.The improvement effect at 11 th week was better than that at 6th week.The mechanism may be through regulating tubuloglomerular feedback,inhibiting the expression of SGLT1 and SGLT2 in renal proximal tubules,upregulating the level of NKCC2/A1AR/Cx40,and promoting the constriction of the entering arterioles;At the same time,the expression of P38mapk/Cox2/Renin was down-regulated,and the contraction of the bulbous arterioles was inhibited,thereby improving glomerular hyperfiltration. |
PDF Full Text Request