| ObjectiveFirstly,the method of systematic review was used to systematically search and sort out the current research evidence of traditional Chinese medicine colon enema based on rhubarb in the treatment of patients with chronic kidney disease(CKD),understand the research progress and evidence quality in this field,and summarize the current shortcomings and potential improvements.Then,with the help of biological nanotechnology,the mercaptochitosan nanocarriers were constructed and combined with the key components of rhubarb to construct emodin nanocarriers.Then,the protective effects of new emodin nanoparticle on gut-related microbiota,intestinal mucosal barrier function and kidney injury in rat models of CKD were further studied through animal experiments to reveal the mechanism of emodin nanoparticle to delay the progression of CKD.Finally,in vitro cell studies,the effects of emodin nanoparticle on oxidative damage and apoptosis of Caco-2 cells induced by H2O2 stimulation were studied,and through in vivo and in vitro experiments,the effects of emodin nanoparticle "gut-bacteria" co-modulation in the treatment of chronic kidney disease were jointly revealed.Methods1.The efficacy and safety of rhubarb enema for CKD patients in non-dialysis stage were systematically evaluated:By Chinese medicine or Chinese herbs or medicinal plants or rhubarb or roots)and(enema or colon dialysis or enema)and chronic kidney disease or chronic renal failure or chronic renal insufficiency or uremia,The relevant literatures published from the database establishment to September 2021 were retrieved from PubMed,EMBASE,Cochrane Central Register of Controlled Trials Central,Chinese Biomedical Literature,CNKI,Vipu and Wanfang.Literature was screened according to inclusion and exclusion criteria,and data extraction,quality assessment and data analysis were carried out for literatures that met the criteria.2.Animal experiments:In this study,Emodin nanoparticle were prepared first,and then the drug adhesion effect of emodin fluorescence(FITC)nanoparticles on colon enema was studied by IVIS in vivo imaging system.Further,5/6 nephrectomized rats were used as chronic kidney disease models,and the rats were randomly divided into Sham group,5/6 nephrectomy model group(5/6Nx group),emodin nanoparticle low-dose group,emodin nanoparticle high-dose group and emodin group.The frequency of emodin nanoparticle low and high dose enema was once every two days,and emodin enema was once a day for 8 weeks.Collect blood,urine,stool,kidney and colon samples at the end of the study.Renal function,urinary protein quantization,HE staining in pathological sections of kidney and intestine,Masson staining in pathological sections of kidney,serum IL-1β,IL-6,LPS and DAO levels were detected by ELISA,and the expression levels of TLR4,MyD88,NF-κB and in colon tissues were detected by western-blot and fecal gut microbiota was detected by 16SrDNA sequencing.3.Cell experiment:In this study,the damage of human intestinal epithelial cells(Caco-2)induced by H2O2 stimulation was used as a model to simulate the corrosion damage of intestinal tract caused by urinary toxins in chronic kidney disease,and emodin nanoparticle and emodin intervention were given.The protective effect of emodin nanoparticle on H2O2-induced damage of Caco-2 cells was studied by cell morphology,Annexin-PI double staining,MDA,SOD,ROS and mitochondrial membrane potential,to verify the effect of Emodin nanoparticle on intestinal barrier function.Results1.This systematic review included 14 RCT results,including a total of 1400 patients with stage 3-5 CKD.The results showed that rhubarb enema reduced serum creatinine levels and improved eGFR during 15 days to 6 months of treatment compared to saline retention enema.These effects were also observed when compared to charcoal solution enemas and mannitol enemas.There were no significant differences in serum creatinine and eGFR between rhubarb enema group and abdominal dialysis enema group,but there were statistically significant changes in serum creatinine and eGFR between all groups after treatment.There is weak evidence that rhubarb enema,as an adjunct to conventional treatment,improves kidney function by reducing serum creatinine and improving eGFR in patients with CKD.However,due to the short follow-up time,the long-term benefits of rhubarb enema are unclear.Due to insufficient reports of safety outcomes,no conclusions can be drawn about the safety of rhubarb based enema in patients with CKD.Long-term follow-up and well-designed trials are warranted.With the development of biotechnology,it may be beneficial to improve the dosage form of enema.In this study,through the use of biological nanotechnology,mPEG-PLA-CS-MBI emodin colon adhesion nanomedicine was successfully constructed.2.Emodin nanoparticle had strong colon adhesion at 12h,and still had strong colon adhesion at 48h,but no nanoparticle adhesion at 72h.Therefore,in animal experimental studies,emodin nanoparticle colon enema treatment frequency was once every two days.Compared with sham operation group,serum creatinine,urea nitrogen and 24 h urinary protein in 5/6Nx model group were significantly increased(P<0.05).HE and Masson staining of renal tissue showed renal tubule enlargement,monocyte infiltration,tubule atrophy and interstitial fibrosis in 5/6Nx model group.Compared with 5/6Nx model group,the serum creatinine level of rats in high-dose emodin nnanoparticle group and emodin group was significantly decreased(P<0.05).The high-dose emodin nanoparticle can improve the renal histopathological changes of 5/6Nx rats,and reduce the degree of renal mononuclear lymphocyte infiltration and renal tubule interstitial fibrosis.The curative effect of high-dose emodin nanoparticle enema treatment is slightly better than that of daily emodin enema treatment.Compared with 5/6Nx model group,the levels of urinary protein and serum urea nitrogen in emodin nanoparticle low dose group,high dose group and emodin group were not significantly reduced.Compared with sham operation group,serum levels of IL-1β,IL-6 and LPS in 5/6Nx model group were significantly increased(P<0.05).Compared with 5/6Nx model group,serum levels of IL-1β,IL-6 and LPS in high-dose emodin nanoparticle group and emodin group were significantly decreased(P<0.05).HE staining of colon tissue in 5/6Nx group showed that compared with sham operation group,colon mucosa and lamina propria of 5/6Nx group showed significant edema,mucosal lymphocyte and monocyte infiltration.After emodin nanoparticle or emodin colon enema,the infiltration of inflammatory cells in the mucosal layer was reduced,and the edema of the mucosal layer and lamina propria was significantly improved.The serum DAO level of 5/6Nx group was significantly higher than that of sham operation group(P<0.001),the DAO level of emodin nanomedical low-dose group and emodin group was decreased,the DAO level of emodin nanomedical low-dose group was slightly lower than emodin group,and the serum level of emodin nanomedical high-dose group was significantly lower than that of 5/6Nx group(P<0.05).The expressions of TLR4,MyD88 and NF-κB in the colon tissue of the sham operation group were significantly lower than those of the 5/6 Nx model group(P<0.05).The expression in 5/6 Nx model group was significantly higher than that in 5/6 Nx+emodin nanomedical or emodin groups(P<0.05).The results of intestinal flora analysis showed that the gut microbiota enriched in the sham operation group were clostridium and Pasteurella.The low and high doses of emodin nanoparticle enriched clostridium,butyricum and Romboutsia,while the emodin nanoparticle enriched paracenobacter and anaerobic.Multilevel and multigroup difference analysis showed that Barnesiella was enriched in rats in the sham operation group.The emodin nanoparticle enema group enriched Romboutsia,Butyricicoccus,parabobacteroides and Clostridium.Pair-to-pair comparison showed that compared with the sham operation group,the number of saccharomyces.Clostridium,trichomyces and firmicutes decreased in the 5/6Nx model group.The quantity of Clostridium,Romboutsia and Blautia in emodin treated group was significantly higher than that in 5/6Nx model group.The levels of saccharomyces,clostridium,butyricococcus and Helicobacillaceae were increased in the emodin nanoparticle low-dose group,while the levels of clostridium,Aloprevotella.Romboutsia,Oscillibacter,Ruminococcus and Turicibacter were increased in the emodin nanomaterial high-dose group.The difference between emodin nanoparticle and emodin treatment group was that there were more sugar bacteria in emodin nanoparticle treatment group and more streptococcus in emodin treatment group.The difference between the emodin nanoparticle group and the high-dose group was that the number of Bacteroides,Phascolarctos and Ruminococcus increased in the low-dose emodin nanoparticle group,while the number of Akkermansia increased in the high-dose emodin nanoparticle group.RDA results showed that gut microbes were significantly correlated with systemic inflammation and LPS in serum samples,and body weight was positively correlated with Clostridium.IL-1β was positively correlated with Bacteroides,butyriciccoccus and Faecalibacter.IL-6 was negatively correlated with isoprevotella,Eubacterium and Fusicatenibacter.Serum LPS was negatively correlated with Bacteroides,faecalis and streptococcus.3.Cell experiment:In this study,the damage of Caco-2 cells induced by hydrogen peroxide(H2O2)was used as a model,and emodin nanoparticle and emodin were used as intervention drugs,to study whether Emodin nanoparticle have direct protective effects on intestinal mucosal barrier.In our results,compared with Normal group,Caco-2 cells in H2O group showed abnormal morphology,marked degeneration,damage and shrinkage of cells after H2O2 stimulation,increased floating cells and disappeared hollow vacuoles of cell population.The apoptosis rate of Caco-2 cells was significantly increased,and the contents of MDA and ROS in cells were increased.SOD activity and mitochondrial membrane potential decreased.After emodin nanoparticle treatment,the morphology of Caco-2 cells tended to be normal and apoptosis decreased,while mitochondrial membrane potential and SOD level recovered,ROS content and MDA content decreased,and emodin nanoparticle efficacy was superior to emodin.Conclusion1.Rhubarb based Chinese medicine enema therapy as an adjunct therapy for chronic kidney disease,due to the uncertainty of short-term evidence and lack of long-term evidence,this systematic review cannot make specific recommendations.Long-term follow-up and well-designed trials are warranted.With the development of bio-high-tech industry,it may be beneficial to improve the dosage form of enema.Colon adhesion emodin nanoparticle have good colon adhesion and lasting time.Emodin nanoparticle colon enema alleviates systemic inflammation,renal tubulointerstitial fibrosis and improves renal function by changing gut microbiota disturbance in 5/6 nephrectomized rats.Emodin nanoparticle treatment once every two days is as effective as emodin treatment once a day.3.In cell experiments,emodin nanoparticle can inhibit the oxidative stress damage of Caco-2 induced by H2O2 and alleviate apoptosis.Emodin nanoparticle have a direct role in protecting intestinal epithelial cells and improving intestinal mucosal barrier function.4.Emodin nanoparticle colon enema can play a protective role in chronic kidney disease through the "gut-bacteria" co-regulation,providing a new idea and method for traditional Chinese medicine to treat kidney from the gut. |
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