Meta-analysis And Network Pharmacology Study Of Traditional Chinese Medicine In The Treatment Of Chronic Kidney Disease With Damp-heat Syndrome

Background:Syndrome of interior dampness-heat is the common type of syndrome in protracted course of Chronic kidney disease(CKD),the incidence of which is as high as 47.8%～100%.Dampness-heat is the pathological products of CKD,and the important pathogenesis as well,increasing and accelerating the progress of the clinical course of CKD,and plays an important role.There is a close relationship between the occurrence of CKD development and dampness-heat,so it is particularly important to prevent and treat the syndrome of dampness-heat in CKD.Network pharmacology is a new discipline based on the theory of systems biology,which aims to analyze the network of biological system,selects a specific signal node for multiple targets drug molecular designing.Network pharmacology explains the occurrence and development of diseases from the perspective of systems biology and the balance of biological network,finds the interactions of drug-body and guides the discovery of new drugs from a holistic perspective of improving or restoring the balance of biological networks.The integrity and systematic characteristics of network pharmacology is consistent to the principles of treatment based on syndrome differentiation Chinese medicine.Thus,network pharmacology has been widely used in the research of traditional Chinese medicine.This study aims to summarize and analyze the effectiveness and clinical medication rules of clearing heat and promoting diuresis therapy of TCM in the treatment of CKD.Explore the mechanism of the medicine with clearing heat and promoting diuresis therapy in the treating CKD by using network pharmacology method preliminarily.Study one:Meta-analysis of Clearing Heat and Promoting Diuresis Therapy for Chronic Kidney DiseaseObjective:To evaluate the effectiveness of clearing heat and promoting diuresis therapy in the treatment of CKD and summarize the clinical medication rules.Method:Computer retrieval of Chinese National Knowledge Infrastructure(CNKI),VIP Database for Chinese Technical Periodicals(VIP),Wanfang digitize Database,SinoMed,PubMed,Cochrane Library and Web of science databases to collect data on oral clearing heat and promoting diuresis method in the treatment of CKD from randomized controlled trials(RCTs),which were published as of April 2020.This search task is completed by two people together.If there is any difference of opinion,it can be solved through consultation with the third person.Cochrane collaboration quality evaluation form was used to assess the literature’s quality.The STATA software version 15 was employed to manage and analyze data.And summarize the rule of medication based on literature data extraction.Results:1.Literature inclusion:A preliminary search of 892 literatures was conducted through the network database,and 33 literatures were included in the final analysis,which met the inclusion requirements of the meta-analysis.A total of 2558 patients with CKD were involved,all from China,including 1308 in the experimental group and 1250 in the control group.2.Usage of traditional Chinese medicine:The literatures included in this study were all based on the clearing heat and promoting diuresis therapy of TCM.The top 10 traditional Chinese medicines in the list of frequency from high to low were Poria codex,Codonopsis pilosula,Glycyrrhizae Atractylodes diffusa,Atractylodes diffusa,rhizoma coptidis,pinellia pinellia,cassia twiggy and Scutellaria baicalin.3.The assessment of literature quality:The 33 articles are described by random allocation methods,only 15 articles were randomly assigned with random number table method,and some concrete methods of random 14 articles were not described,4 articles were carried out in accordance with the doctor order randomly assigned.Only 1 article the allocation scheme for sealed envelopes in advance,the remaining 32 articles did not describe whether the distribution of hidden one paper by double blind method,the rest of the 32 articles were not made clear whether to impose a double-blind method.4.The results of Meta-analysis:The primary results of this meta-analysis demonstrated that CKD patients treated by clearing heat and promoting diuresis therapy of TCM combined with conventional western medicine had got the effective improvement in eGFR level[WMD=5.289,95%CI(2.879,7.703),P<0.05,I2=66.8%]BUN[WMD＝-1.284,95%CI(-1.776,-0.793),P<0.05,I2=88.6%],the syndrome score of traditional Chinese medicine[WMD=-6.883,95%CI(-8.542,-5.224),P<0.05,I2=95.7%]、compared to the control group who used conventional western medicine only.Meanwhile,the combined treatment plan can reduce Scr[WMD=-14.027,95%CI(-18.704,-9.349),P<0.05,I2=81.4%]and 24-hour urinary protein quantity(24h UP)[WMD=-0.382,95%CI(-0.461,-0.290),P<0.05,I2=69.7%]at the same time.In terms of improving eGFR,different stages of CKD may be one of the sources of heterogeneity in eGFR overall studies.As for the reduction of Scr level,with the progression of the disease course of CKD,the absolute value of the effect of oral clearing heat and promoting diuresis method on the reduction of Scr in patients with CKD also increased,and the overall data showed that compared with the control group,Scr level showed a decreasing trend.Furthermore,subgroup analysis showed that the Scr reduction effect was better in patients with hyperuricemic nephropathy.5.The publication bias and sensitivity analysis of articles:The results of regression asymmetry test of Begg’s and Egger suggested that there was publication bias in all studies.The number of potential missing studies was further evaluated by non-parametric shear and complement method for each outcome indicator,and there no supplemental studies were found,this indicated that publication bias has little effect and the results were relatively robust.The sensitivity of the included articles was analyzed by the method of successive exclusion of single studies.The point estimates of all the results fell within 95%CI of the combined effect size,indicating that the overall stability of the results of this study was strong.Conclusion:1.Oral TCM medicinal decoction by clearing heat and promoting diuresis therapy on the basis of conventional treatment may have advantages in improving laboratory indicators related to renal function in patients with CKD,but high-quality evidence is needed for further research.2.There are 5 medicines including coptidis rhizoma,scutellariae radix,arum ternatum thunb,glycyrrhiza uralensis fisch and codonopsis pilosula in most frequently used traditional Chinese medicines in the 33 included articles were consistent with the formulation of Banxia-Xiexin decoction,a classic prescription in TCM,which efficacy is corresponding to the TCM pathogenesis of CKD,can be used as a reference for clinical treatment of dampness-heat in syndrome differentiation of CKD.Study two:Study on the mechanism of the medicines which are related to treating chronic kidney disease with dampness-heat syndromebased on network pharmacology and molecular dockingObjective:To explore the potential mechanism of the medicines which are related to treating chronic kidney disease with dampness-heat syndrome by using network pharmacology and molecular docking.Method:1.Based on the summary and analysis of the high-frequency traditional Chinese medicines used in the included literatures,the second part of this study intends to choose Banxia-Xiexin Decoction as the representative prescription for the treatment of CKD with dampness-heat syndrome.Collecting the active compounds and targets of Banxia-Xiexin decoction:Through the TCMSP database,Banxia-Xiexin decoction was collected to make up the pharmaceutical chemical compounds.The effective compounds were selected as the following:oral bioavailability(OB)≥20%,drug-likeness(DL)≥0.1,and the targets were screened in the TCMSP database as well.2.Collection of CKD targets:Screening the keyword "chronic kidney disease" through GeneCards and OMIM databases respectively to search for target related to CKD.3.Herb-active compounds-potential target-disease network construction and the core components selection:Plotting the Venn diagram of drug-disease intersection targets by R software as the potential targets of Banxia-Xiexin decoction in the treatment of CKD and constructing the "herb-active compounds-potential targets-disease" network using Cytoscape 3.8.0 software.The core components were selected for further research based on the results of network topology analysis.4.Protein-protein interaction(PPI)network construction and the core targets selection:The potential targets of Banxia-Xiexin decoction in treating CKD were imported into the STRING database to obtain the protein interaction information of the potential targets.Meanwhile,using Cytoscape 3.8.0 software to construct PPI network diagram and perform topology analysis,the core targets were screened for subsequent research.5.Annotation analysis of biological functions of core targets:Gene Ontology(GO)and Kyoto Encyclopedia of Genes and Genomes(KEGG)pathways of Banxia-Xiexin decoction for the treatment of CKD were analyzed using R.6.Molecular docking:Molecular docking these core compounds and targets to verify the reliability of the results by Autodock Vina software.Results:1.Banxia-Xiexin decoction active compounds and targets:328 active compounds were screened through TCMSP database and 278 targets were obtained.2.CKD related targets collection:149 human targets related to CKD were searched in GeneCards and OMIM databases.3.Collection of active compounds of Banxia-Xiexin decoction for treating CKD:The targets of Banxia-Xiexin decoction were matched with CKD related targets,and the intersection targets were selected as the targets of Banxia-Xiexin decoction for the treatment of CKD,and 149 drug-disease action targets were finally obtained.Cytoscape 3.8.0 software was used to construct targets network for topological structure analysis,and the top 10 active compounds were obtained,suggesting that they might be the main pharmacological substances of Banxia-Xiexin decoction in the treatment of CKD.4.Collection of intersection targets of Banxia-Xiexin decoction for treating CKD:149 drug-disease targets were imported into the STRING database to obtain the protein-protein interaction information.CytoNCA plug-in in Cytoscape was further used to calculate the network node attributes,and 23 core targets were obtained,including insulin(INS),albumin(ALB),interleukin-6(IL6),cystine-aspase-3(Caspase-3),Epidermal growth factor receptor(EGFR),CASP3,and so on.5.GO ontology and KEGG pathway analysis:There 23 key targets affected 89 biological processes and 113 signaling pathways.It is mainly through PI3k/Akt signaling pathway,MAPK signaling pathway,cancer associated signaling pathway and HIF-1 signaling pathway and so on to play a role in the treatment of CKD.6.Molecular docking:In 230 sets of molecular docking score,there were 10 groups of-9,95 groups between-9 and-7,and 92 groups between-7 and-5.The results showed that the active compounds in Banxia-Xiexin decoction had strong binding activity with the key targets.Conclusion:This study discovered active compounds and key targets of Banxia-Xiexin decoction by the perspective of network pharmacology.This study reflects the characteristics of "multi-component,multi-target and multi-path" of Banxia-Xiexin decoction,and provides reference for further study on the mechanism of Banxia-Xiexin decoction in treating CKD.Summary:Through the first part of this research,the clinical efficacy of clearing heat and promoting diuresis method in the treatment of CKD was systematically evaluated and meta-analyzed by searching the literature,which concluded that oral TCM medicinal decoction by clearing heat and promoting diuresis therapy on the basis of conventional treatment may have advantages in improving laboratory indicators related to renal function in patients with CKD,but high-quality evidence is needed for further research.The traditional Chinese medicines frequently used in the included literature were mostly consistent with the formulation of Banxia-Xiexin decoction,which can be used as a reference for clinical treatment in CKD with dampness-heat syndrome differentiation.Based on the results of the first part of the study,further exploration was carried out.Taking Banxia-Xiexin decoction as an example,it was found through network pharmacological method that Banxia-Xiexin decoction plays a therapeutic role through the synergistic relationship of multi-herbs,multi-ingredients and multi-targets.The mechanism may play through quercetin and β-sitosterol acting on the targets of INS,ALB,IL6,CASP3,EGFR,and CYCS,which may also be related to the PI3K/Akt and MAPK signaling pathway.