A Systematic Review And Meta-analysis Of Integrated Traditional Chinese And Western Medicine In The Treatment Of Hepatorenal Syndrome

research foundationHepatorenal syndrome(HRS)is the functional renal failure secondary to severe liver disease.once occurring.the disease progresses rapidly and the survival rate is extremely low.The pathogenesis of hepatorenal syndrome is quite complicated,involving multiple targets,links and pathways.At this stage,the curative effect of western medical treatment is limited,and the combination of traditional Chinese medicine treatment may be a research path with feasible theory and predictable effect.A certain number of case reports,retrospective analysis and small sample size randomized controlled trials have confirmed that combined TCM treatment for hepatorenal syndrome can indeed improve short-term liver and kidney function and prolong survival,with certain dominant significance.However,due to the low level of evidence,clinical studies with higher level of evidence are needed to demonstrate the effectiveness and safety of integrated traditional Chinese and western medicine in the treatment of hepatorenal syndrome.research objectivesTo evaluate the efficacy and safety of integrated traditional Chinese and western medicine in the treatment of hepatorenal syndrome through the systematic review and meta-analysis.To explore the treatment thoughts and the rules of the drug use of TCM treatment of hepatorenal syndrome through The usage of drugs in the relevant literature.research methodsThrough searching databases(Pubmed.Embase,the Cochrane Library,CNKI and Wanfang,VIP.CBM),collecting qualified documents,and evaluating quality of literature.Then,extract,merge,and analyze the data(total effective rate.SCr,BUN,ALT,ALB,TBIL,PTA,mortality,and adverse reactions).Choose Revman5.3 statistical analysis software.Heterogeneity test:I2<50%,select fixed effect modelLI2>50%,select subgroup analysis.If the heterogeneity problem cannot be solved by subgroup analysis,the descriptive analysis is selected.dichotomous variable selects The odds ratio(OR)ratio,and the confidence interval(CI)is 95%.The continuous variables selects the mean difference(MD),and the confidence interval(CI)is 95%.The mantel-haenszel method is used to calculate the dichotomous variable.The calculation method of continuous variables is inverse variance.Z test is selected to determine whether the combined effect size has statistical significance:P>0.05,there is no statistical significance;P<0.05,there is statistical significance.The results of Meta analysis are presented by forest plot and make sensitivity analysis on heterogeneous results.If there are a large number of literatures,funnel plot is used to analyze the potential bias.At the same time,the use of traditional Chinese medicine in treating hepatorenal syndrome is summarized and analyzed.research resultsThis systematic review included 14 articles,involving 1041 patients with hepatorenal syndrome,including 653 male patients and 388 female patients.The research indicators include total effective rate,SCr,BUN,ALT,ALB,TBIL,PTA,mortality and adverse reactions.1 Total Effective RateMeta analysis results show that the combination of traditional Chinese medicine is more advantageous in total effective rate.(I2=0%,OR=4.21,95%CI=[3.00,5.91],P<0.00001).2 Renal FunctionSCr and BUN are selected as evaluation indexes.The results indicate that the combination of traditional Chinese medicine is more advantageous in improving short-term renal function.SCr was divided into 5 subgroups:①"Western medicine vs western medicine+Chinese medicine:SCr<180 mol before treatment" group,I2=0%,MD=-17.57,95%CI=[-18.50,-16.64],P<0.00001。②Western medicine vs western medicine+Chinese medicine:SCr≥180mol before treatment" group,I2=0%,MD=-54.97,95%CI=[-67.42,-42.52],P<0.00001。③"Ascites concentration and transfusion vs ascites concentration and transfusion+Chinese medicine:SCr<500 mol/1 before treatment" group,I2=0%,MD=-30.11,95%CI=[-39.93,-20.30],P<0.00001。④"Ascites concentration and transfusion vs ascites concentration and transfusion+Chinese medicine:SCr≥500 mol/1 before treatment" group only contains one study,MD=-143.00,95%CI=[-168.11,-117.89],P<0.00001。⑤"Artificial liver plasmapheresis vs artificial liver plasmapheresis+Chinese medicine" group only contains one study,MD=-59.80,95%CI=[-69.90,-49.70],P<0.00001。BUN was divided into 4 subgroups:①"Western medicine vs western medicine＋Chinese medicine:BUN<21.4mmol/l before treatment”group,I2=39%,MD=-2.27,95%CI=[-2.43,-2.11],P<0.00001。②"Western medicine vs western medicine+Chinese medicine:BUN≥21.4mmol/l before treatment”group,I2=0%,MD=-7.73,95%CI=[-9.40,-6.06],P<0.00001。③"Ascites concentration and transfusion vs ascites concentration and transfusion+Chinese medicine" group,I2=97%,describing each study individually,Cao YJ 2018(MD=-13.30,95%CI=[-15.99,-10.61]),Chai M 2018(MD=-2.08,95%CI=[-2.69,-1.47]),Yao Y2018(MD=-2.89,95%CI=[-3.30;-2.47])。④"Artificial liver plasmapheresis vs artificial liver plasmapheresis+Chinese medicine" group only contains one study,MD=-1.60,95%CI=[-2.86,-0.34],P=0.01。3 Liver FunctionALT.ALB.TBIL and PTA are selected as evaluation indexes.The results indicate that the combination of traditional Chinese medicine is more advantageous in improving short-term liver functionALT was divided into 2 subgroups:①"ALT<200IU/L”group,I2=0%,MD=-47.66,95%CI=[-53.52,-41.81],P<0.00001。②"ALT≥200IU/L"group,I2=0%,MD=-32.36,95%CI-[-40.05.-24.66],P<0.00001。ALB was divided into 3 subgroups:①”Western medicine vs western medicine+②"Chinese medicine" group,I2=0%,MD=4.50,95%CI=[3.45,5.54],P<0.00001。Ascites concentration and transfusion vs ascites concentration and transfusion+Chinese medicine" group only contains one study,MD=10.01,95%CI=[6.54.13.48],P<0.00001。③"Artificial liver plasmapheresis vs artificial liver plasmapheresis+Chinese medicine”group only contains one study,MD=1.90,95%CI=[1.00,2.80],P<0.0001。TBIL was divided into 3 subgroups:①"TBIL<150μmol/l"group,I2=31%,MD=-25.09,95%CI=[-26.96,-23.22],P<0.00001。②"TBIL≥150μmol/l"group,I2=0%,MD=-48.31,95%CI=[-61.07,-35.56],P<0.00001。PTA was divided into 2 subgroups:①"Western medicine vs western medicine+Chinese medicine" group,I2=11%,MD=9.54,95%CI=[6.79,12.28],P<0.00001。②"Artificial liver plasmapheresis vs artificial liver plasmapheresis＋Chinese medicine" group only contains one study,MD=22.20,95%CI＝[14.27,30.13],P<0.00001。4 Long-term PrognosisThere are only 3 literatures which report mortality during follow-up period(I2-0%,OR=0.27,95%CI=[0.12,0.61],P=0.002).Although the data are less,it also shows that to some extent,the combination of Chinese and western medicine can reduce the mortality of patients with hepatorenal syndrome.5 Safety AssessmentThere are only 3 literature which reports adverse reactions during the process of the treatment:Qie LX 2014 study(Dopamine combined with Chinese medicine enema)、Qin XY 2011 study(artificial liver plasma exchange combined with rhubarb enema)、Yao Y 2018 study(ascites ultra-filtration concentration and transfusion combined with oral administration of traditional Chinese medicine),To some extent,these three studies show that the safety of combined TCM treatment is guaranteed,but the level of evidence is insufficient.6 Analysis on the Use of Traditional Chinese MedicineThe 14 literatures involve four traditional Chinese medicine treatment methods:oral,enema,acupoint application,Chinese patent medicine.Two Chinese patent medicines and 47 traditional Chinese medicines were used in the literature.The most frequently used drugs are tonifying drugs,diuretics and blood-activating and blood-stasis drugs.The 9 kinds of traditional Chinese medicines that use most are atracty lodes,tuckahoe,astragalus membranaceus,salvia miltiorrhiza,alisma orientalis,angelica,cassia twig,aconite,rhubarb.Oral decoction is mainly used for tonifying drugs,diuretics,and activating blood and removing blood stasis drugs.The six drugs with the highest frequency of use are atractylodes atractylodes.alisma orientalis,poria cocos,astragalus,salvia miltiorrhiza,and aconite.The main idea of oral medicine is to warm Yang and invigorate qi,invigorate blood and invigorate water.Enemas are mainly tonic drugs,purgative drugs and blood-activating and blood-stasis drugs.The four most frequently used herbs are rhubarb,atractylodes.salvia miltiorrhiza and safflower.The main idea of enema is dispelling blood stasis and removing turbidity,as well as strengthening the body.Acupoint application involves two traditional Chinese medicines,namely garlic and mirabilite.Chinese patent medicine is danhong injection.Through drug analysis,it is found that the treatment of hepatorenal syndrome in traditional Chinese medicine is strengthening the body resistance,diuresis.defecation and removing blood stasis.research conclusionThe treatment of hepatorenal syndrome with integrated traditional Chinese and western medicine can improve the total effective rate,improve short-term liver and kidney function,and reduce the mortality to a certain extent.Due to the lack of data,the safety assessment of integrated traditional Chinese and western medicine in the treatment of hepatorenal syndrome is insufficient,but there are no reports of serious adverse reactions.There are many ways to treat hepatorenal syndrome in traditional Chinese medicine,such as oral administration,enema,acupoint application or Chinese patent medicine.Through drug analysis,it is found that the treatment of hepatorenal syndrome in traditional Chinese medicine is strengthening the body resistance,diuresis,defecation and removing blood stasis.Although it has certain limitations,the results of this study show that the combination of Chinese and western medicine in the treatment of hepatorenal syndrome can indeed improve the curative effect,improve the liver and kidney function and long-term prognosis,so far there are no reports of serious adverse reactions.In the future,a multi-center,large-sample randomized controlled double-blind trial or a systematic evaluation or meta-analysis involving more high-quality original research literature is needed to provide more rigorous evidence.