Shou-Yu Huang, Ning Zhang?, Ting Fang, Rong-Lu Yang

1. Department of Nephrology and Endocrinology,Wangjing Hospital of China Academy of Chinese Medical Sciences,Beijing 100102,China

2. Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine,Beijing 100700,China;3. Graduate School,Beijing University of Chinese Medicine,Beijing 100029,China

Keywords:Shenshuaining granule Diabetic kidney disease Meta analysis Randomized controlled trial

ABSTRACT Objective: To systematically review the efficacy and safety of Shenshuaining granule combined with Western medicine treatment for Diabetic kidney disease (DKD) by metaanalysis. Methods: Databases including CNKI, WanFang Data, VIP, CBM, TheCochrane,Embase and PubMed were electronically searched from inception to May 2020 to collect randomized controlled trials of Shenshuaining granule with western medicine treatment for Diabetic nephropathy. The trial was screenedbased on inclusion and exclusion criteria, and the methodological quality of the included relevant trial was assessed by Cochrane Handboo-k.Meta-analysis was then performed by Revman 5.3 software. Results: A total of 9 studies involving 892 patients were included. Both groupinclude 446 patients.The result of metaanalysis showed that Shenshuaining granule combined with Western medicine treatment significantly improved the total effective rate of diabetic nephropathy [RR=1.26,95%CI(1.17,1.37),P＜0.00001], further reduced ser umurea nitrogen [MD=-1.65,95%CI(-2.53,-0.77),P=0.0002], 24h urine albumin excretion rat [SMD=-4.21,95%CI(-6.23,-2.19),P＜0.0001],serum creatinine [MD=-21.50,95%CI(-28.48,-14.50),P＜0.00001]. However, the difference of fasting blood glucose [MD=-0.46,95%CI(-1.18,0.27),P=0.22]was not statistically significant.Conclusions: Shenshuaining granule can improve the rate o-f renal pellet filtration in patients with diabetic nephropathy, reduce kidney injury and protect kidney function.Although there are sideeffects, it is relatively safe.

1. Introduction

Diabetic kidney disease(DKD) is one of the most important microvascular complications of diabetes, and 10% of diabetic deaths are caused by kidney diseases. Its clinical manifestations are hyperglycemia, decreased glomerular filtration rate and proteinuria.Pathologically, itis characterized by glomerulosclerosis, basement membrane, extracellular matrix formation, protein accumulation,podocyte loss and tubulointerstitial fibrosis. With the increasing prevalence of diabetes, the incidence of DKD is also increasing year by year, and DKD patients have complex metabolic disorders,which are more likely to develop to end-stage renal disease[1,2]. For DKD, there is no effective therapy in western medicine. At present,symptomatic treatments such as controlling blood sugar and blood pressure and limiting protein intake are the main ones[3], but the effect is not ideal, and it is easy to lead to drug dependence [4,5]. The treatment of DKD with integrated traditional Chinese and western medicine has obvious characteristics and advantages, which can effectively relieve clinical symptoms and delay disease progression.From the perspective of TCM, DKD does not have a clear name of TCM disease, but according to its clinical manifestations, it can be classified into ＂Shen Xiao＂, ＂Gao Lin＂, ＂Xu Lao＂, ＂Shui Zhong＂ and ＂Guan Ge＂. In order to unify the names of diseases, modern Chinese medicine has classified them as ＂Xiao Ke nephropathy＂. Most physicians think that the essence of this disease belongs to the deficiency of origin and the excess of reality, and the key to pathogenesis is deficiency of spleen and kidney combined with dampness and turbidity and blood stasis[6].In order to give full play to the role of Chinese medicine in treating this disease and combine Chinese and Western medicine effectively,there are more and more related clinical studies, among which there are many clinical trials about Shenshuaining Granule combined with Western medicine in treating DKD. In order to further verify the effectiveness and safety of this study, the meta-analysis method was used to systematically evaluate it, so as to provide more effective and valuable basis for future clinical treatment.

2. Data and methods

2.1 Inclusion and exclusion criteria

2.1.1 Inclusion criteria

①Randomized controlled trial of Shenshuaining granule in the treatment of DKD, which were publicly published; ②All subjects were definitely diagnosed as DKD; ③The control group was treated with western medicine alone, while the experimental group was treated with Shenshuaining granule on this basis.

2.1.2 Exclusion criteria:

①The basic information of the article is incomplete, such as incomplete data and unavailable full text, etc; ②Animal experiment;③Nongranular dosage form; ④Shenshuaining granule was not used as experimental group but as control group.

2.1.3 Outcome indicatorsOutcome indicators reflecting effectiveness include total effective rate, UAER, BUN, Scr and Cys-C; Outcome indicators reflecting safety include HbA1c, FBG and adverse reaction.

2.2 Literature retrieval methods

Computer searches CNKI, WanFang Data, VIP, CBM,TheCochrane, Embase, PubMed and other databases, and searches all the controlled trials of Shenshuaining granules in treating diabetic kidney disease. The search time limit is from the establishment of the database to May 2020. ＂Shenshuaining granule＂, ＂Shenshuaining particle＂, ＂Diabetic Nephropathy＂, ＂DN＂ ,and ＂Diabetic kidney disease＂ are used as key words. Search by combining subject words with free words.

2.3 Literature screening and data extraction

Two researchers independently screened the literatures according to the inclusion and exclusion criteria, extracted the data according to the data extraction table, and finally checked each other. If there are differences, discuss and solve them together or consult a third party to assist in judgment. The contents of the data extraction table include the following aspects: ①The first author of the included literature and the year of publication; ②The number of researchers,the ratio of male to female and the average age of the experimental group and the control group; ③ intervention measures; ④ course of treatment; ⑤ Outcome indicators.

2.4 Quality evaluation of the included literature

According to Cochrane's biased risk assessment tool, the quality evaluation of the included literature mainly includes the following aspects: ① the generation of random sequences; ② Hidden situation of distribution scheme; ③ The use of blind method, including whether subjects, researchers and evaluators of research results are blind; ④ Whether the ending data is complete; ⑤ Whether to report selectively; ⑥ Whether there are other sources of bias. In case of disagreement, consult a third party for assistance.

2.5 Statistical analysis

Statistical analysis was carried out by RevMan 5.3 software.Relative risk (RR) is used as the effect quantity for the second classification variable, mean difference (MD) is used as the effect quantity for the continuous variable, and standardized mean difference (SMD) is used for different units of measurement.Each effect quantity is given its point estimation value and 95%confidence interval (CI). The heterogeneity among groups included in the study was analyzed by χ2test (the test level was α=0.1),and the heterogeneity was quantitatively judged by I2. If there is no statistical difference among the results (I2≤50%, P ＞ 0.05), the fixed effect model is used for Meta-analysis. If there is statistical heterogeneity among the research results (I2＞50%, P＜0.05), the random effect model is used for Meta-analysis. Higher clinical heterogeneity should be further analyzed by subgroup analysis or sensitivity analysis, or Make a descriptive analysis.

3. Results

3.1 literature screening process

After preliminary search, a total of 1483 articles, including 299 articles of CNKI, 218 articles of VIP, 278 articles of CBM and 688 articles of Wanfang Data, were searched in Chinese documents,but no English related documents were found. After removing the duplicate literature, there were 579 papers, and then after reading the abstract and the full text, the second screening was carried out according to the inclusion criteria, and finally 9 papers were included. See figure 1 for details.

Figure 1 Flow chart of literature screening

3.2 Basic characteristics of the study

The basic characteristics included in the study are shown in Table 1

3.3 Quality evaluation of the study

All the 9 studies included mentioned random grouping, among which 6 studies[10-15] were grouped according to the random number table method, and the remaining 3 studies[7-9] did not give specific random allocation methods. None of the nine studies mentioned the random concealment of the scheme, the blindness of researchers or subjects, and the blind evaluation of research outcomes. The data of outcome indicators in the included literature are completely reported,and there is no selective report result. (see figure 2)

The quality evaluation of the study is shown in Figure 2.

Figure 2 Quality evaluation of the study

Table 1 Basic characteristics included in the study

3.4 Meta-analysis results

3.4.1 Comparison of total effective rate

Seven studies[7-10, 12, 13 , 15] reported the total effective rate of patients, with a total of 678 patients. Among them, Zhou Pan's research is divided into three groups: early DKD group, normal renal function group in clinical nephropathy stage and renal insufficiency group in clinical nephropathy stage. Heterogeneity test I2=0%, so fixed effect model analysis was adopted. The results showed that the total effective rate of the experimental group was higher than that of the control group, and the difference was statistically significant [RR= 1.26,95% CI (1.17,1.37), P ＜ 0.00001] (see Figure 3).

Figure 3 Total effective forest map

3.4.2 Comparison of urinary albumin excretion rate (UAER)A total of 5 studies[7, 9, 10, 12, 13] reported UAER status of patients,and there were 352 patients in 5 studies. Heterogeneity test I2=97%.Heterogeneity could not be eliminated by sensitivity analysis and subgroup analysis of treatment course, age and control intervention drugs, so random effect model was used for analysis. The results showed that the UAER in the experimental group was better than that in the control group, and the difference was statistically significant[SMD=-4.21, 95%CI(-6.23, -2.19), P＜0.0001] (see Figure 4).

Figure 4 UAER forest map

3.4.3 Comparison of urea nitrogen (BUN)A total of 9 studies[7-15] reported the BUN status of patients, with a total of 892 patients. Among them, Zhou Pan and Li Baiyun [11,15] were divided into three groups: early DKD group, normal renal function group in clinical nephropathy stage and renal insufficiency group in clinical nephropathy stage. Heterogeneity test I2=97%.Heterogeneity could not be eliminated by sensitivity analysis and subgroup analysis of treatment course, age and control intervention drugs, so random effect model was used for analysis. The results showed that the BUN in the experimental group was better than that in the control group, and the difference was statistically significant[MD=-1.65, 95%CI(-2.53, -0.77), P=0.0002] (see Figure 5).

Figure 5 BUN forest map

3.4.4 Comparison of cystatin C (Cys-C)

Cys-C was reported in 4 studies[7, 9, 10, 12], with a total of 274 patients. Heterogeneity test I2=91%. Heterogeneity could not be eliminated by sensitivity analysis and subgroup analysis of treatment course, age and control intervention drugs, so random effect model meta-analysis was adopted. The results showed that the decrease of Cys-C in the experimental group was significantly better than that in the control group (MD =-1.34, 95%CI(-2.08, -0.60), P = 0.0004) (see Figure 6).

Figure 6 Cys-C forest map

3.4.5 Comparison of serum creatinine (Scr)A total of 5 studies[7, 8, 11, 14, 15] reported the Scr status of patients,with a total of 650 patients. Among them, Zhou Pan and Li Baiyun[11, 15] were divided into three groups: early DKD group, normal renal function group in clinical nephropathy stage and renal insufficiency group in clinical nephropathy stage. Heterogeneity test I2=95%.Heterogeneity could not be eliminated by sensitivity analysis and subgroup analysis of treatment course, age and control intervention drugs, so random effect model was used for Meta-analysis. The results showed that the Scr reduction of the experimental group was significantly better than that of the control group, and the difference was statistically significant [MD=-21.50, 95%CI(-28.48, -14.50), P ＜0.00001] (see Figure 7).

Figure 7 Scr forest map

3.4.6 Comparison of fasting blood glucose (FBG)A total of 6 studies[7, 8, 10, 12-14] reported FBG status of patients,with a total of 486 patients. Heterogeneity test I2=93%, and there is heterogeneity among the research results. The random effect model analysis shows that there is no significant difference between the experimental group and the control group in reducing FBG [MD=-0.46, 95%CI(-1.18, 0.27), P=0.22] (see Figure 8).

Figure 8 FBG forest map

3.4.7 Comparison of adverse reactions

A total of 6 studies[7, 8, 10, 13-15] reported adverse reactions (27 cases in total, including 12 cases in the experimental group and 5 cases in the control group), among which 4 studies[7, 8, 13, 14]reported the types and cases of adverse reactions, and 2 studies reported the types of adverse reactions. Most of the reported adverse reactions were gastrointestinal reactions (10 cases in total, including 6 cases in the experimental group and 4 cases in the control group),such as diarrhea, nausea, vomiting, dizziness and headache (7 cases in total, including 2 cases in the experimental group and 5 cases in the control group), hypoglycemia (6 cases in total, including 3 cases in the experimental group and 3 cases in the control group) There was no statistical heterogeneity among the studies (I2=0%). Metaanalysis with fixed effect model showed that there was no significant difference in the incidence of adverse reactions between the two groups. [RR = 0.80,95% ci (0.39,1.66), P=0.55] (see fig. 9).

Figure 9 Forest map of incidence of adverse reactions

4. Discussion

At present, the pathogenesis of DKD is not completely clear, and some studies suggest that it is closely related to hemodynamic changes, metabolic disorders, inflammatory reactions, autophagy,cytokines, oxidative stress and genetic factors[16], which needs further study. Shenshuaining has the effects of invigorating qi and spleen, promoting blood circulation and removing blood stasis,and dredging fu-organs and expelling turbid. Its components include Salvia miltiorrhiza, rhubarb, Pinellia ternata, Poria cocos,Achyranthes bidentata, Pseudostellaria heterophylla, Coptis chinensis, Carthamus tinctorius, Pericarpium Citri Tangerinae and Glycyrrhiza uralensis Fisch. Modern pharmacological studies have found that rhubarb, one of its components, can not only inhibit hypermetabolism and compensatory hypertrophy of kidney and promote excretion, but also inhibit protein decomposition and promote its massive synthesis, thus improving azotemia[12, 17]. In addition, the research of Example et al.[18] found that Shenshuaining can improve blood flow, promote toxin excretion, weaken kidney hypermetabolism and protect kidney function. Research by Jiang Lili et al[19]. shows that Shenshuaining Granule can inhibit NF-κB expression, activate PPAR-γ expression, improve glomerular and capillary structure and protect renal function.

The results of this meta-analysis showed that compared with the control group, the total effective rate of the experimental group was significantly improved, BUN, Scr, Cys-C and UAER were further reduced, and the clinical efficacy was better. Studies have shown that in order to effectively reflect the renal damage of patients, the combined application of BUN, Scr and Cys-C is a better method[20].Compared with BUN and Scr, Cys-C is not affected by other factors such as diet, exercise, etc., and has good sensitivity and can more accurately evaluate glomerular function[21]. After analysis, the effect of reducing BUN, Scr and Cys-C in the experimental group is more significant, which indicates that Shenshuaining has a good effect on promoting creatinine excretion, improving azotemia, improving glomerular filtration rate and reducing renal function damage in patients with DKD. UAER is positively correlated with the degree of renal damage[22]. According to the meta-analysis results of UAER,it is suggested that the renal function of patients can be effectively improved by combining Shenshuaining. Because the western medicine treatments used in the included studies are inconsistent, it also reflects that Shenshuaining Granules can be used together with many western medicines to protect the kidney. FBG is an important research index of blood sugar control level. Analysis shows that there is no significant difference between the two groups in reducing FBG.Even so, to some extent, it suggests that Shenshuaining granule has no obvious effect on lowering blood sugar and improving blood sugar level, but it will not weaken blood sugar level when combined with related western medicine therapy. There is no significant difference in adverse reactions between the two groups, suggesting that Shenshuaining is safe in treating DKD. However, due to the limitation of the quality and quantity of included literatures, the above problems need to be proved by more high-quality clinical trials.

This meta-analysis has the following shortcomings: ① The number of included literatures is small, and the studies are all small samples;② Some studies are unclear about the generation, distribution hiding and blind method of random sequences, and there may be bias risk;③ Among the 9 studies included, one study[7] was based on the DKD diagnostic standard of Diabetic Nephropathy Diagnosis, Syndrome Differentiation and Therapeutic Evaluation Standard (Trial Scheme)issued by Nephrology Branch of Chinese Traditional Medicine Association in 2007. One study[10] was based on the diagnostic criteria of DKD in Nephrology, 3rd edition of People's Health Publishing House in 2008. 1 study[11] according to the diagnostic criteria of DKD in the 2007 American Clinical Practice Guide for Diabetes and Chronic Kidney Disease; One study[15] was based on the DKD diagnostic criteria of Diabetic Nephropathy-Endocrinology,People's Health Publishing House, 2nd Edition, 2010. Other studies did not mention specific diagnostic criteria. Patients included in two studies[8,10] belong to the third stage of DKD with reference to the Mogensen staging method, and patients included in two studies[11,15]are divided into three groups according to the DKD staging standard in people's health publishing house, 2nd edition, 2010, ＂diabetic nephropathy-endocrinology＂. Considering that the included studies have different reference standards for DKD diagnosis and staging, it may also be the reason for the high heterogeneity of some outcome indicators; ④ The course of study included has not exceeded 3 months, and there is no long-term follow-up, so the long-term effect of Shenshuaining Granule combined with western medicine therapy on DKD patients cannot be confirmed.

To sum up, compared with conventional western medicine therapy,combined with Shenshuaining Granule has better effect on DKD,which provides a basis for future clinical application. At present, the global prevalence rate of DKD is on the rise, which has become a serious disease threatening human life[23]. How to effectively apply traditional Chinese medicine in clinical practice and find more active treatment methods is still the focus of future research.