| Diabetic kidney disease（DKD）is a common microvascular complication of diabetes mellitus.According to statistics,the proportion of ESRD events caused by DM has reached 31.3%worldwide.As the number of DM patients in China is gradually increasing,the DKD is on the rise as a cause of ESRD year by year.DKD has posed a serious threat to the health of Chinese people,and it has also brought a huge burden to the development of social economy.Therefore,it is a pressing challenge for the medical science sector to provide specific therapeutic drugs against this disease.As the research on the mechanism related to intestinal flora has been enriched and deepened in recent years,its relationship with the development of DKD has been gradually elucidated,providing new ideas on the pathogenesis and treatment of this disease.With many years of clinical experience,my supervisor has proposed the core pathogenesis of DKD as "Internal heat causing zheng jia" based on the viewpoint in the Internal Canon of Medicine that the stagnation of evil qi in the two yang is the cause of heat in the intestines and stomach,which is often the cause of diabetes.He also created the Qingre Xiaozheng Formula as the main treatment option,and achieved good clinical results.In the preliminary study,it was found that this formula has the effects of reducing proteinuria,alleviating renal pathological damage and regulating intestinal flora disorder in DKD model mice,and also has certain regulatory effects on lipid metabolism.Therefore,this paper will further investigate the connotation of "internal heat is the cause of the disease" from both clinical studies and animal experiments,and explore the connection between intestinal flora,lipid metabolism and the development of DKD.Objectives:1 To analyze the association between bile acids and the development of DKD and the correlation between bile acids and "internal heat" by comparing the biochemical indexes and serum total bile acid levels between patients with DM and DKD,and between patients with DKD of internal heat and non-internal heat.2 To observe the effects of the Qingre Xiaozheng Formula on various physicochemical indexes,intestinal flora and bile acid metabolism in DKD mice,and to explore the efficacy and specific mechanism of the treatment of DKD with the Qingre Xiaozheng Formula.Methods:Clinical part:General data and TCM syndrome information were collected from patients with type 2 DM and patients with DKD,and all DKD patients were divided into internal heat syndrome group and non-internal heat syndrome group based on the internal heat syndrome score.The differences in general conditions,biochemical indices and serum total bile acid levels between the groups were analyzed,as well as the correlation between serum total bile acid and biochemical indices and internal heat syndrome scores.Animal experiment:The DKD mouse model was prepared by high-fat feeding+STZ modeling method,and divided into normal group,model group,Chinese medicine group and western medicine group.Each group of mice was administered for 8 weeks,and subsequently body weight,blood glucose,ACR,urinary albumin concentration,serum total cholesterol,serum triglycerides,blood creatinine,urea nitrogen,serum LPS,serum bile acid profile assay and intestinal flora assay were measured to analyze the differences between the groups.Results:Clinical part:1 There were significant differences in the comparison of urea,uric acid,blood creatinine,24h urine protein quantification,total cholesterol,triglycerides,HDL,serum total protein,serum albumin,TBIL,DBIL,ALT,and AST between patients in the DM group and DKD group,and there were no statistically significant differences in the remaining indexes.Compared with the DM group,there was no statistically significant difference in serum total bile acid level in the DKD group,and there was no significant difference in total bile acid level in patients with each stage of DKD.Correlation analysis showed that total bile acid levels in DKD patients were positively correlated with triglycerides,AST and ALT,and negatively correlated with low-density lipoprotein.There were no significant correlations for the remaining indicators.There was a statistically significant positive correlation between total bile acid levels and history of non-alcoholic fatty liver disease in DKD patients.No significant correlation was seen between it and history of hypertension and coronary artery disease.2 There was a significant difference in total bile acid levels between patients in the internal heat group and non-internal heat group in DKD,with patients in the internal heat group having significantly higher total bile acid levels than those in the non-internal heat group.Patients with internal heat symptom of DKD were mainly distributed in the early and middle stages,while patients with non-internal heat symptom of DKD were mainly distributed in the middle and late stages.Compared with the patients in the internal heat group,the urea and blood creatinine levels were significantly higher and the serum albumin,AST and TBIL levels were significantly lower in the non-internal heat group,but there were no statistical differences in other indexes.Correlation analysis showed that there was a statistically significant positive correlation between total bile acids and the internal heat symptom score in DKD patients.Moreover,there was a positive correlation between it and the symptoms of internal heat,such as red lips and mouth,boils and sores,redness and pain,irritability,dry throat and thirst,thirst for cold drinks,excessive food and hunger,sticky mouth and smelly breath,yellow urine,dry or sticky stools,and red tongue with yellow coating.Animal experiment:1 ACR and urinary albumin concentrations were significantly higher in the model group mice compared with the normal group,and pharmacological interventions in the herbal and western medicine groups significantly reduced the levels of both,and no significant differences in the results were seen between the two groups.In terms of blood lipids,total serum cholesterol and triglyceride levels were significantly higher in the model group compared with the normal group.In the TCM group,total cholesterol levels were significantly lower than those in the model group,and triglyceride levels also showed a decreasing trend.The levels of both indicators in the Western medicine group were not significantly different from those in the model group.The LPS level of mice in the model group was significantly higher than that in the normal group,and the LPS level of mice in the TCM group decreased significantly after the intervention,but there was no relevant change in the Western medicine group.The blood glucose levels of mice in the model group,Chinese medicine group and western medicine group were significantly higher than those in the normal group,and there was no significant effect of drug intervention on the blood glucose levels of DKD mice in this study.2 The Simpson and Shannon diversity indices of mice in the model group showed an increasing trend compared to the normal group.At the phylum level,the relative abundance of the phylum Thick-walled Bacteria and the phylum Aspergillus increased significantly.The relative abundance of the phylum Bacteroides and Actinobacteria decreased significantly,and the B/F ratio decreased significantly.The relative abundance of Desulfovibrio,Oscillibacter,Corynebacterium1,Ruminiclostridium,Gemella,Allobaculum,Parasutterella and Marvinbryantia at the genus level were significantly increased,while the relative abundance of Alistipes,Parasutterella and Marvinbryantia were significantly increased.And the relative abundance of Alistipes,Parasutterella,unidentified and Bifidobacterium all decreased significantly.The Shannon diversity index of mice decreased significantly after the intervention of Chinese medicine,and the Simpson diversity index also showed a decreasing trend.At the phylum level,the relative abundance of Bifidobacterium thick-walled decreased,and the relative abundance of Bifidobacterium mimicum and B/F ratio were improved to some extent.At the genus level,the relative abundance of Desulfovibrio,Oscillibacter,Corynebacterium1,Ruminiclostridium,and Gemella decreased significantly,while the relative abundance of Alistipe and Parasutterella increased significantly.3 The results of serum bile acid assay showed that the total serum bile acid level of mice in the Chinese medicine group showed a decreasing trend compared with the normal group and the model group.Among all the 64 bile acid components tested,there were 16 different bile acid components between the normal group and the model group mice,and 7 different bile acids between the Chinese medicine group and the model group mice.Among them,two bile acid components,taurocholic acid and taurodeoxycholic acid,tended to be elevated in the model group,and the Chinese herbal medicine intervention could make them decrease to some extent.Correlation analysis revealed that serum taurocholic acid content was positively correlated with urinary protein concentration,while it was negatively correlated with Turicibacter and positively correlated with Bacteroides and Desulfovibrio.Conclusions:1 The total bile acid level of DKD patients is closely related to the internal heat symptom,which may be the material basis of "Internal heat is the cause of the disease" and plays an important role in the development of the disease.2 Qingre Xiaozheng Fang can reduce urinary albumin concentration and ACR level in DKD mice,regulate lipid metabolism level in mice to some extent,reduce serum LPS level,and improve histopathological damage of kidney.3 The intestinal flora of DKD mice was significantly in disorder compared with normal mice,and the disorder was under control after the application of Qingre Xiaozheng Fang.The intestinal flora may be a key part of the production of "internal heat" in the body and the effect of traditional Chinese medicine to "clear heat".4 Qingre Xiaozheng Fang can correct the disorder of bile acid metabolism in DKD mice,and its key components may be taurocholic acid and taurodeoxycholic acid.Its correlation with the abundance of flora related to bile acid metabolism suggests that Qingre Xiaozheng Fang may have therapeutic effects by correcting intestinal flora disorders and regulating bile acid metabolism. |
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