Advances in anti hepatic fibrotic therapy with Traditional Chinese Medicine herbal formula

Journal Pre-proof Advances in anti hepatic fibrotic therapy with Traditional Chinese Medicine herbal formula Hui Li PII:

S0378-8741(19)33273-8

DOI:

https://doi.org/10.1016/j.jep.2019.112442

Reference:

JEP 112442

To appear in:

Journal of Ethnopharmacology

Received Date: 19 August 2019 Revised Date:

27 November 2019

Accepted Date: 27 November 2019

Please cite this article as: Li, H., Advances in anti hepatic fibrotic therapy with Traditional Chinese Medicine herbal formula, Journal of Ethnopharmacology (2020), doi: https://doi.org/10.1016/ j.jep.2019.112442. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier B.V.

Advances in Anti Fibrotic Therapy with Traditional Chinese Medicine Herbal Formula Hui Li* Central Laboratory, Hospital of Chengdu University of Traditional Chinese Medicine, NO. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, P. R. China

Abstract The process of liver fibrogenesis includes a number of common and etiology-dependent or independent mechanisms and events. Up to now, approved biological or chemical therapies directly targeting and reversing advanced fibrosis are still lacking. Traditional Chinese Medicine (TCM) has unique advantages in anti-liver fibrosis due to its characteristics of TCM syndrome differentiation, treatment and holistic view. Studies have made tremendous progress on using herbs, ingredients and herbal formulae to treat liver fibrosis patients or animals, and this paper will focus on the development of herbal formulae to treat liver fibrosis. Keywords liver fibrosis; anti fibrotic therapy; Traditional Chinese Medicine; herbal formula

Advances in Anti Hepatic Fibrotic Therapy with Traditional Chinese Medicine Herbal Formula Hui Li* Central Laboratory, Hospital of Chengdu University of Traditional Chinese Medicine, NO. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, P. R. China

ABSTRACT ETHNOPHARMACOLOGICAL RELEVANCE: The process of liver fibrogenesis includes a number of common and etiology-dependent or independent mechanisms and events. Up to now, there are still insufficient approved biological or chemical therapies directly targeting and reversing advanced fibrosis. The key is that once liver fibrosis is triggered, it presents a complex network control model with the activation of HSCs as the core, resulting in poor efficacy of treatment. Traditional Chinese medicine (TCM) has unique advantages in treating hepatic fibrosis because of its

syndrome differentiation and treatment and comprehensive pharmacological

effects of multi-channel, multi-level and multi-target. However, TCM’s advantages were rarely discussed as previous reviews focused on the active ingredients of TCM and single Chinese Medicine. Therefore, this paper focuses on TCM herbal formulae’s pharmacological role, target and related mechanisms in the treatment of liver fibrosis. AIM OF THE STUDY This paper will focus on the pharmacological role, target and related mechanisms of TCM herbal formulae in the treatment of liver fibrosis. MATERIALS AND METHODS: We collect English literatures or Chinese literatures with English Abstract on the treatment of liver fibrosis with TCM herbal formulae from databases including PubMed, Wiley InterScience, Science Direct OnSite/Elsevier, Ovid, Excerpta Medica Database, SpringLink, CNKI and China Biomedical Literature Database. Based on previous literatures, we summarize the TCM herbal formulae with definite anti-hepatic fibrosis effects. RESULTS: To some extent, classical or modern TCM herbal formulae including Yinchenhao Decoction, Xiayuxue Decoction, Xiaochaihutang, Yiguanjian Decoction, Huangqi *Corresponding author: Hui Li, NO. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, P. R. China; E-mail address: [email protected]， Tel:+862887766349

1

Decoction, Dahuang Zhechong Pills, Fuzheng Huayu Formula, Fufang Biejia Ruangan Tablets, Anluo Huaxian Pills and Compound 861 have anti-hepatic fibrosis effect both on patients with liver fibrosis and animal models with liver fibrosis. CONCLUSION: According to the principle of syndrome differentiation and treatment, Liver fibrosis patients with different syndromes are treated with different herbal formula, which increases the difficulty of clinical efficacy research. XCHD and XYXD research lack randomized and controlled clinical trials. XCHT, YGJ and HQD research has small sample sizes despite randomized and controlled clinical trials. In contrast, most modern herbal formulae have randomized and controlled clinical trials. For instance, FZHY and ALHX recently published the research results of the combination of entecavir in the treatment of patients with chronic hepatitis B liver fibrosis or cirrhosis. Compared to anti-viral treatment with entecavir alone, this method has improved the reversion rate of liver fibrosis but still needs syndrome classification therapy of TCM. TCM Herbal formulae have a good prospect in treating liver fibrosis, but its composition of multiple drugs and a wide range of targets intensify the difficulty of studying their anti-hepatic fibrosis mechanisms. Future research needs to further study the anti-hepatic fibrosis mechanisms and select corresponding TCM herbal formula to treat patients with different syndromes of liver fibrosis or the same patient with different syndromes at different stages to achieve better curative results. KEYWORDS: liver fibrosis; anti hepatic fibrotic therapy; Traditional Chinese Medicine; herbal formula

1. Introduction Liver fibrosis is tissues’ wound-healing response to injury characterized by excessive accumulation of extracellular matrix (ECM) (Yoon et al., 2016). Chronic Hepatitis B viral infection, Chronic Hepatitis C viral infection and alcoholic or non-alcoholic fatty liver disease (ALD and NAFLD) are the most common etiologies of fibrosis. Other etiologies include drug induced liver disease, autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis, Wilson’s disease, hemochromatosis and α1-anti- trypsin deficiency (Parola and Pinzani, 2019 ). Cirrhosis, which is the final stage of liver fibrosis, is one of the major health-related 2

concerns worldwide. According to global reports, cirrhosis results in about 1 million deaths annually (Ebrahimi et al., 2018; Rowe, 2017). Treating hepatic fibrosis is an important way to effectively prevent progression to cirrhosis or hepatocellular carcinoma. Chronic liver injury is a core event that initiates fibrosis and activated hepatic stellate cells (HSCs) is a key target in liver fibrosis. Once liver fibrosis is triggered, it presents a complex network regulation model. Cascades of reactions stimulate quiescent HSCs into their activated forms, leading to the accumulation of ECM components (Higashi et al., 2017). Current biological or chemical drugs focus on eliminating the etiology, alleviating hepatocyte inflammation, inhibiting the activation of hepatic stellate cells, promoting the apoptosis of activated hepatic stellate cells, etc., which often result in poor efficacy, because they only act on one of the targets (Yoon et al., 2016; Friedman, 2015). Nowadays, there is still a shortage of approved therapies directly targeting and reversing advanced fibrosis. As in cancer therapies, drugs that address more than a single pathogenic pathway are usually more efficient than single highly specific pathway modulators in the treatment of liver fibrosis (Schuppan et al., 2013). Similarly, drugs targeting multiple pathways or regulating multiple components in core signaling are more appealing than compounds affecting only parts of a complex network (Yoon et al., 2016). It has been claimed that TCM has unique advantages in anti-liver fibrosis due to its TCM syndrome differentiation, treatment, holistic view and multi-target pharmacological action (Luk et al., 2007). Over the past 20 years, there has been tremendous progress made in treating liver fibrosis with TCM, which provides new opportunities for future treatment of this condition. Lam P et al. pointed out their anti-inflammation and anti-oxidation properties and hepatoprotective effects of Chinese Medicine Herbs (Lam et al., 2016) and Hong M et al. reviewed pharmacological role and molecular mechanisms of several medicinal herbs in treating chronic liver diseases (Hong et al., 2015). Moreover,Wang et al. indicated that Chinese Medicine might have potential to both prevent hepatocellular carcinoma (HCC) occurrence and retard HCC progression (Wang et al., 2015). Zhang et al. compared the differences between TCM and Western Medicine in the treatment of liver fibrosis and introduced some traditional Chinese medicine prescriptions for the treatment of liver fibrosis (Zhang and Schippan, 2014). However, these reviews mainly focused on the effect of single active components of TCM, insufficient when investigating the important role of TCM in the prevention and treatment of liver 3

fibrosis. In fact, in the clinical practices, TCM herbs do not work independently, but are prescribed in formulae. This paper will examine the role and mechanism of herbal formulae in treating liver fibrosis.

2. Traditional Chinese Medicine Herbal Formulae for Liver Fibrosis Treatment TCM herbal formulae are generally composed of herbs, animal organs or mineral, which have been used in China and other Asian countries for thousands of years. Although lots of studies, including many clinical trials, have proved that TCM herbal formulae have multiple targets in treating liver disease, the relevant mechanisms of these herbal formulae are still not fully understood (Hong et al., 2015). This paper aims to introduce some classical herbal formula and modern herbal formula with anti-fibrosis effect. English literatures and Chinese literatures with English abstract in this review come from databases including PubMed, Wiley InterScience, Science Direct OnSite/Elsevier, Ovid, Excerpta Medica Database, SpringLink, CNKI and China Biomedical Literature Database. Anti-hepatic fibrosis herbal formula of TCM introduced in this paper, contents and duplicated herbs in herbal formula are listed in Table 1. 2.1 Yinchenhao Decoction (YCHD) YCHD is a classical TCM herbal formula for the treatment of damp-heat syndrome of liver and gallbladder since the Han Dynasty. It has a history of more than 1800 years and is still one of the basic prescriptions for the treatment of liver and gallbladder diseases. YCHD is composed of Yinchenhao(Artemisia capillaris Thunb), Zhizi (Gardenia jasminoides J. Ellis), and Dahuang (Rheum officinale Baill) (Cai et al., 2019). Aqueous extract of YCHD protects mouse liver from concanavalin A (ConA)-induced acute inflammation and liver injury (Cai et al., 2006; Jiang et al., 2015) through the inhibition of Nuclear factor kappaB (NF-κB) activation (Cai et al., 2006), reducing the cell apoptosis through regulating the expressions of FasL and Bcl-2 (Wang et al., 2008). YCHD also ameliorates liver injury, hepatic apoptosis and improves liver fibrosis through down-regulate monocyte chemoattractant protein-1 (MCP-1) , tissue inhibitor of metalloproteinase-1 (TIMP-1) and platelet derived growth factor subunit B (PDGF-B) in bile duct ligation rats (Lee et al., 2007; Lee et 4

al., 2007; Lee et al., 2009; Wang et al., 2015). Recent study showed that anti-fibrotic effects of YCHD might be associated with Transform Growth Factor Beta1 (TGFβ1) down regulation and recovering and rebuilding self-regulation of the renin-angiotensin system (RAS) by elevating the protein expression of angiotensin II (ACE2) (Wu et al., 2015). In a rat model of dimethylnitrosamine (DMN)-induced liver fibrosis, YCHD significantly improved liver function and pathological changes and reduced collagen content in liver tissue (Liu et al., 2008; Liu et al., 2008; Liu et al., 2010; Sun et al., 2011; Bian et al., 2012; Wang et al., 2014). The therapeutic effects of YCHD may be attributed to the inhibition of oxidative stress and resulting lipid peroxidation (Zhang et al., 2016), obstruction of proliferation and activation of HSCs through TGF-β1/Smad/ extracellular regulated protein kinases (ERK) signaling pathway in liver fibrosis (Cai et al., 2018). But in CCL4-induced liver fibrosis rats, hepatoprotective effect of YCHD has not yet been observed (Sun et al., 2011; Tao et al., 2009; Mu et al., 2006). In addition, YCHD has therapeutic effect on chronic hepatitis B, which is the most important cause of liver fibrosis (Xu et al., 2019). YCHD is commonly used to treat liver fibrosis patients with damp heat syndrome in liver and gallbladder and the liver fibrosis model induced by CCl4 should not be hepatobiliary dampness heat syndrome, which is the viewpoint of traditional Chinese medicine testing syndrome by formula. 2.2 Xiayuxue Decoction (XYXD) XYXD is another classical recipe contemporary with YCHD that has been widely applied in clinical practices for treating liver disease. It consists of three medicinal herbs: Dahuang (Rheum officinale Baill), Taoren (Semen Persicae), and Zhechong (Eupolyphaga Seu Steleophaga). In rat liver fibrosis models induced by CCl4, XYXD alleviated hepatic pathological changes, reduced content of hydroxyproline (Hyp) in liver tissue and improved hepatic function (Tao et al., 2009; Mu et al., 2006). XYXD could hinder angiogenesis by decreasing the activities of matrix metalloproteinase 2 (MMP-2) and MMP-9, hampering the activation of HSCs through the inhibition of NF-κB and TGF-β1 signaling pathway, and damaging the new vessel integrality (Du et al., 2011; Liu et al., 2015). In CCl4 induced mice models, XYXD inhibited both HSCs activation and sinusoidal endothelial cells (SECs) defenestration which accompany chronic liver injuries and reversed the myofibroblastic HSCs into quiescent (Zhang et al., 2014). In addition, XYXD has protective effects on other organs of liver fibrosis 5

or cirrhosis model animals. XYXD significantly improved renal injury by promoting macrophage apoptosis in rats with damaged renal histopathology in rat models of biliary duct ligation (BDL)-induced liver cirrhosis (Liu et al., 2015). XYXD treatment reduced intestinal inflammation, cell death, and tight junction disintegrity in mouse model induced by CCl4 (Ma et al., 2017). 2.3 Xiaochaihutang (Sho-saiko-to, XCHT) XCHT, also known as Sho-saiko-to in Japan, is a classical TCM herbal formula that has been widely applied for more than 1800 years in chronic liver diseases. XCHT is composed of seven Chinese herbs, including Chaihu (Bupleurum chinense DC.), Huangqin (Scutellaria baicalensis Georgi), Renshen (Panax ginseng C.A. Mey), Banxia (Pinellia ternate (Thunb.) Makino), Shengjiang (Zingiber officinale Roscoe), Dazao (Ziziphus Jujuba Mill), and Gancao (Glycyrrhiza uralensis Fisch). Liver fibrosis rat model induced by CCl4 demonstrated that XCHT was an effective therapeutic formula to treat liver fibrosis. The mechanism could be making further inhibition of activated HSCs by the up-regulation of the Nuclear Factor Erythroid 2-related Factor 2 (Nrf2) pathway against oxidative stress (Amagaya et al., 1989; Hu et al., 2018; Li et al., 2017). XCHT could also reduce the activation of HSC-T6 cells by regulating nrf-2 signal pathway (Hu et al., 2019). In rat liver fibrosis model induced by DMN, XCHT extract is also effective in treating liver inflammation and fibrosis up to a certain degree of severity (Kusunose et al., 2002; Shimizu et al., 1999). XCHT treatment resulted in dose-dependent upregulation of MMP-2, 13 mRNA and downregulation of tissue inhibitor of metalloproteinase 1 (TIMP-1) mRNA (Sakaida et al., 2004). In the rat model through bile duct ligation (BDL), XCHT showed anti-fibrotic potential by reducing the collagen content and fibrogenic score, as well as downregulating elevated procollagen alpha1 types (I) and (III) , TGF-β1, PDGF and TIMP-1 mRNA level (Chen et al., 2004; Chen et al., 2005). Research of Takahashi et al. showed that XCHT inhibited the necroinflammation and fibrosis in the liver of a mouse model of nonalcoholic steatohepatitis (NASH) (Takahashi et al., 2014). In addition, XCHT could promote clearance of HBeAg in children with chronic HBV infection and improve hepatic function of hepatitis C patients (Lee et al., 2011; Tajiri et al., 1991; Deng et al., 2011). But there are side effects such as interstitial pneumonia when treating chronic liver disease with XCHT (Deng et al., 2011). 2.4 Yiguanjian Decoction (YGJ) 6

YGJ, first described in an ancient book in the 18th century, contains six herbs: Beishashen (Adenophora stricta Miq), Shengdi (Rehmannia angulata (Oliv.) Hemsl.), Maidong (Ophiopogon japonicus (Thunb.) Ker Gawl.), Danggui (Angelica sinensis (Oliv.) Diels), Gouqizi (Lycium barbarum L.), and Chuanlianzi (Melia toosendan Siebold & Zucc.). This decoction has been used to treat liver diseases in China for over three centuries (Wang et al., 2012). YGJ Decoction exerted significant therapeutic effect on CCl4 induced fibrosis or cirrhosis in rats through mechanism of inhibiting hepatocytes apoptosis and hepatic stellate cells activation, regulating the function of Kupffer cell, decreasing collagen secretion, and promoting collagen fiber degradation and anti-oxidative stress (Mu et al., 2009; Shen et al., 2010; Wang et al., 2011; Tao et al., 2012). YGJ can also regulate the dysfunction of energy metabolism, amino acid metabolism, tryptophan metabolism, cytochrome P450 metabolism, and gut microflora metabolism (Gou et al,. 2013). YGJ inhibited liver angiogenesis in cirrhotic mice treated with CCl4 by inhibiting the hypoxia-inducible factor-1α (HIF-1α)/ vascular endothelial growth factor (VEGF) signaling pathway, which suggested that anti-angiogenic effects of YGJ was associated with improving the hepatic hypoxic microenvironment (Zhou et al., 2015). In addition, YGJ showed hepatoprotective and anti-fibrogenic effects against DMN-induced hepatic injury (Lin et al., 2011). YGJ could effectively hinder the DNA damage in immunological liver injury mice, possibly through decreasing tumor necrosis factor-α (TNF-α) and increasing the Bax and MutT Homolog 1 (MTH1) expression (Tian et al., 2016). YGJ enhanced fetal liver stem/progenitor cell (FLSPC) -mediated repair of liver cirrhosis through regulating macrophage activation state. When combined with stem cell transplantation, YGJ may be a suitable treatment for end-stage liver cirrhosis (Xu et al., 2018). Combined treatment of YGJ and Adefovir Dipivoxil Tablet (ADT) could significantly improve symptoms of Chinese medicine and fibrosis degree of liver of HBeAg negative chronic viral hepatitis B active compensated liver cirrhosis patients (Duan et al., 2016). 2.5 Huangqi Decoction (HQD) Huangqi decoction, also called Huangqi Liuyi decoction, has been used for more than a thousand years since the Song Dynasty. It was first described in the Prescriptions of the Bureau of Taiping People’s Welfare Pharmacy. HQD consists of two medicinal herbs, Huangqi (Astragalus aaronii (Eig) Zohary) and Gancao 7

(Glycyrrhiza uralensis Fisch), mixed in a 6/1 (wt/wt) ratio (Du et al., 2012). In rat model with DMN-induced cirrhosis, anti-oxidative stress action should be an important mechanism for HQD in reversing liver cirrhosis of rats and with its focus of enhancing anti-oxidation ability of the organism (Wang et al., 2008). More results showed that HQD could decrease hepatocyte apoptosis, promote Kupffer cell activation, regulate bile acid metabolism enzyme and down-regulate expression of some genes related to liver fibrosis, such as PDGF, collagen typeⅠalpha 1 chain (Col1A1), Col1A2, and TGFβ1 (Liu et al., 2012; Zhang et al., 2015; Song et al., 2016). HQD could inhibit cholangiocyte proliferation, cholangiocyte transdifferentiation and activation of TGFβ1-Smad3, TGFβ1-ERK1/2 and Notch signaling pathways in rats with BDL-induced cholestatic liver fibrosis (Du et al., 2012; Du et al., 2010; Qiu et al., 2010; Zhang et al., 2017). HQD also protected mice against chronic cholestatic liver injury and biliary fibrosis, which may be associated with the induction of the Nrf2 pathway and inhibition of the NF-κB pathway, ameliorating bile acid -stimulated inflammation (Li et al., 2019). Recent study explored the mechanism of HQD by randomly dividing 70 patients with hepatitis B cirrhosis into HQD group and control group (35/35 cases) and assigning them with HQD or placebo for 48 weeks. And they concluded that cell division cycle 42 (CDC42) and GLI family zinc finger 1 (GLI1) might be the targets of HQD in patients with hepatitis B cirrhosis (Cheng et al. 2019). 2.6 Dahuang Zhechong Pills (DHZC) DHZC has been used over 1800 years in China as a classical TCM herbal formula that consists of 12 herbs including Dahuang (Rheum officinale Baill), Zhechong (Eupolyphaga Seu Steleophaga), Huangqin (Scutellaria baicalensis Georgi), Gancao (Glycyrrhiza uralensis Fisch),Taoren (Prunus persica (L.) Batsch), Xingren (Prunus armeniaca L.), Baishao (Paeonia Lactiflora Pall.), Shengdi (Rehmannia angulata (Oliv.) Hemsl.), Ganqi (Resina Toxicodendri), Mengchong (Tabanus bivittatus Matsumura), Shuizhi (Whitmania pigra Whitman), and Qicao (Holotrichia) (Cai et al., 2010). A meta-analysis shows that DHZC can reduce serum biomarkers of liver fibrosis such as HA, type-III procollagen, type-IV collagen and LN in patients with chronic hepatitis B (Wei et al., 2015). Combined DHZC and adefovir dipivoxil could prevent liver fibrosis in patients with chronic hepatitis B (Zhang et al., 2012). DHZC could reduce the levels of serum transaminase, globulin and bilirubin, and 8

hepatobiliary scintigraphy index in patients with cirrhosis (Cheng et al., 2008). 62 patients with advanced schistosomiasis were divided randomly into two groups and treated with DHZC and routine therapy, respectively. There were significant differences in the levels of ALT and total bilirubin (TBIL), the indexes of hepatic fibrosis, portal venous inside diameters and portal venous flow between the two groups after 52 weeks treatment (Niu et al., 2011). DHZC could ameliorate liver fibrosis in rat model induced by CCl4 by alleviating TNF-α and IL-13, decreasing p38 and ERK phosphorylation (Cai et al., 2010). In addition, DHZC increased expression of MMP-1 and MMP-2, decreased TGF-β1 level of HSCs, and obstructed proliferation of HSCs by inhibiting PI3K/Akt signal pathway (Li et al., 2003; Pan et al., 2005; Gong et al., 2019). 2.7 Fuzheng Huayu Formula (FZHY) FZHY, also known 319 recipe, consists of six Chinese herbs, including Taoren (Prunus persica (L.) Batsch), Dongchongxiacao (Cordyceps sinensis (Berk.) Sacc), Jiaogulan (Gynostemma aggregatum C.Y.Wu & S.K.Chen), Danshen (Salvia miltiorrhiza Bunge), Songhuafen (Pollen Pini) and Wuweizi (Schisandra chinensis (Turcz.) Baill.) (Liu et al., 1996). FZHY tablet was China Food and Drug Administration (CFDA)-approved anti fibrotic medicine and was the first TCM formula that completed a US Food and Drug Administration (FDA) phase II clinical trial for liver disease treatment (Hong et al., 2015). A large number of research results have confirmed the effectiveness of FZHY in treating patients with liver fibrosis or cirrhosis. For HBV related liver damage, FZHY showed better therapeutic effect than Dahuang Zhachong Pills, Heluo Shugan Capsule and Anluo Huaxian Pills in down-regulating the levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), glutamyl transpeptidase (GGT), hyaluronic acid (HA), type Ⅲ procollagen (P-III-P) and HBV DNA concentration, and alleviating liver fibrosis by decreasing the ratio of TGF-β1/BMP-7 and TGF-β1/Smad3 signaling pathway (Liu et al., 1996; Liu et al., 1998; Liu et al., 2003; Liu et al., 2005; Hu et al., 2006; Tang et al., 2012; Wang and Liu, 2018). FZHY could improve liver fibrosis index of chronic hepatitis B patients who achieve a sustained virological response (SVR) through antiviral therapy (Tian et al., 2013). A randomized, double-blind and placebo-controlled trial showed therapeutic efficacy of FZHY in HBV-caused cirrhosis and improved Child-Pugh score (Chen et al., 2016; 9

Deng et al., 2013) and direct regulation of many important pathways, including but not limited to cell cycle, p53 signaling pathway, and TGF-β signaling pathway (Chen et al., 2015). The results of a few meta-analysis showed that FZHY effectively improved the liver function and HBV-DNA negative conversion rate, alleviated hepatic fibrosis, decreased Child-Pugh score, and relieved TCM symptoms caused by liver dysfunction, indicating that FZHY may have contributed to the alleviation of liver fibrosis and cirrhosis (Wang et al., 2018; Dong et al., 2015). Combination of FZHY with peginterferon α-2a (Pegasys) inhibited liver fibrosis and cell apoptosis in patients with genotype 1 hepatitis C infection (Zhang et al., 2014). In addition, FZHY could effectively reduce the risk of variceal bleeding and improve survival rates for cirrhotic patients with varices, especially when combined with Propranolol (Gu et al., 2013; Ge et al., 2017; Xiao et al., 2014). FZHY also showed good therapeutic effect in animal liver fibrosis model. FZHY could efficiently alleviate hepatic fibrosis induced by CCl4 or DMN. It significantly attenuated acute liver injury and hepatic apoptosis, and inhibited liver fibrosis by decreasing expression of α-SMA, connective tissue growth factor and hepatic hydroxyproline and inhibiting HSC activation. The anti-fibrotic effect of FZHY was also associated with the downregulation of mRNA and protein expression of TIMP-1, PDGF-B, PDGFR-β, TGF-β1, TβR-I and Smads. FZHY could impede liver collagen production, block the insulin like growth factor (IGF)/ phosphatidylinositol 3-kinase (PI3K) pathway related to progression of liver fibrosis, regulate cell proliferation and transformation and reduce lipid peroxidation induced by DMN. Furthermore, FZHY could ameliorate nutritional fibrosing steatohepatitis and attenuate liver fibrosis by activating hepatic NK cells. Therefore, the anti-fibrotic effects of FZHY emerge through multiple targets, functions, and pathways. FZHY, when combined with HQD, could better lower collagen deposition in liver fibrosis in DMN induced rats than FZHY or HQD alone(Liu et al., 2006; Liu et al., 2006; Liu et al., 2007; Cheung et al., 2009; Cheng et al., 2013; Wu et al., 2013; Tao et al., 2014; Zheng et al., 2015; Chen et al., 2016; Dong et al., 2018; Hu et al., 2019; Liu et al., 2001; Wang et al., 2010; Wang et al., 2012; Xie et al., 2013; Jia et al., 2012; Wang et al., 2015; Gao et al., 2016; Liu et al., 1998 ). Recent study also found that FZHY could reduce autophagy induced by rapamycin (Huang et al.). 2.8 Fufang Biejia Ruangan Tablets (FFBJRG) FFBJRG was the first antifibrotic herb formula approved by CFDA in 1999, 10

composed of Biejia (Carapax trionycis), Ezhu (Rhizoma curcumae), Chishao (Paeonia Lactiflora Pall.), Danggui (Angelica sinensis (Oliv.) Diels), Sanqi (Panax notoginseng (Burkill) F.H.Chen), Dangshen (Codonopsis pilosula (Franch.) Nannf.), Huangqi (Scutellaria baicalensis Georgi), Ziheche (Placenta hominis), Dongchongxiacao (Cordyceps sinensis (Berk.) Sacc), Banlangen (Isatis indigotica Fortune ex Lindl.), and Lianqiao (Forsythia suspensa (Thunb.) Vahl). FFBJRG could alleviate clinical symptoms and liver fibrosis in patients with chronic hepatitis B and more effective than control group (heluoshugan capsule) (Chen et al., 2007). The combination of FFBJRG and entecavir in hepatitis B virus (HBV)-related cirrhosis or liver fibrosis showed better therapeutic effect on decreasing serum levels of ALT, AST, HBV DNA, HA, laminin (LN), collagen type Ⅰ and prolyl endopeptidase than the other two groups that use entecavir or FFBJRG alone (Wu et al., 2014; Yang et al., 2016). With the purpose of systematically assessing the effect of FFBJRG on biochemical and virological parameters in hepatic fibrosis or cirrhosis in patients with CHB, a systematic review and meta-analysis aimed to reveal that FFBJRG has a more positive effect on the patients with hepatic fibrosis or cirrhosis (Huang et al., 2019). A multicenter, centrally randomized, double-blind, placebo-controlled, parallel-group study was conducted to establish whether FFBJRG can prevent or delay the development of HCC by blocking and reversing hepatic fibrosis in CHB or HBV related compensated in nine institutions between November 2013 and November 2018, however, the research results has not yet been published (Qu et al., 2014). FFBJRG reduced serum levels of HA, LN, type Ⅳ collagen and P-III-P, inhibited hepatic collagen deposition and improved hepatic lesions in liver fibrosis rat model induced by CCl4, which might be associated with down regulation of fibrogenic signal transduction of the TGF-β-Smad pathway (Huang et al., 2019). FFBJRG serum could restrain the proliferation and activation of HSCs, decrease the number of activated HSCs and the excretion of collagens I, III, enhance the degradation of collagen and restore the balance of synthesis and degradation of collagen, and inhibit the expression of TGFβ1 and PDGF in HSCs (Yang et al., 2013; Guo et al., 2004). 2.9 Anluo Huaxian Pills (ALHX) ALHX was the herb formula approved by CFDA for the treatment of chronic 11

hepatitis B and early and mid-term cirrhosis. It consists of Guiban (Shell of Chinemys reevesii (Gray)), Biejia (Shell of Trinyx sinensis Widgmann), Shengdi (Rehmannia angulata (Oliv.) Hemsl.), Sanqi (Panax notoginseng (Burkill) F.H.Chen), Shuizhi (Whitmania pigra Whitman), Dilong (Pheretima aspergillum (E. Perrier), Jiangcan (Bombyx mori Linnaeus), Baizhu (Atractylodes macrocephala Koidz.), Yujin (Curcuma wenyujin Y.H.Chen & C.Ling), Niuhuang (Bezoar), Dahuang (Rheum officinale Baill), and Shuiniujiao (horn of Bubalus bubalis Linnaeus). The combined use of ALHX with IFN-γ could reduce the size of schistosomal egg nodules and the percentage of pigmentation, improve liver fibrosis by reducing the expression of collagen I and III, TIMP-1, and TGF-β1 in schistosomal liver fibrosis of mice. Similar effects, such as protecting liver function, and reducing the portal vein width as well as the spleen thickness, were found in patients with schistosomal liver fibrosis (Huang et al., 2009). ALHX can protect liver function and inhibit liver fibrosis in rats induced by DMN through increasing MMP-2 expression (Tan et al., 2010). ALHX treatment can reverse CCl4-induced liver fibrosis in rats through the inhibition of TGF-β1 synthesis and TGF-β1/Smads signaling pathway, the enhancement of the expression of MMP-13 and the reduction of the expression of MMP-2 and TIMP-1/2 (Lu et al., 2017; Wang et al., 2019). Treatment with ADV in combination with ALHX could enhance anti-fibrotic effect and significantly improve liver histology of chronic hepatitis B patients (Jiang et al., 2012). In addition, a recent research showed that the combination of Anluo Huaxian pills and Entecavir could significantly boost the improvement rate of liver fibrosis and reduce the progress rate in patients with chronic HBV infection (Miao et al., 2019). 2.10 Compound 861 (Cpd861) Cpd861, an empirical formula derived from traditional recipes by Professor Wang Baoen, has been granted a patent. Cpd861 is comprised of Danshen (Salvia miltiorrhiza Bunge), Huangqi (Scutellaria baicalensis Georgi), Chaihu (Bupleurum chinense DC.), Jixueteng (Spatholobus suberectus Dunn), Chuanxiong (Ligusticum chuanxiong), Xiangfu (Cyperus rotundus L.), Chishao (Paeonia Lactiflora Pall.), Chenpi (Citrus reticulata Blanco), Danggui (Angelica sinensis (Oliv.) Diels), and Honghua (Carthamus tinctorius L.) (You et al., 2000). Cpd861 could significantly inhibit HSCs proliferation, promote apoptosis of activated HSCs by obstructing NF-κB binding activity, reduce the expression of 12

endothelin-1 protein, collagen typesⅠ, Ⅲ and Ⅳ (You et al., 2000; You et al., 2001; Ding et al., 2003; Wang et al., 2004; Wang et al., 2008; Stickerl et al., 2002), decrease the fibrous septa and make the sinusoids more regular in rat liver fibrosis model induced by human albumin (Zhang et al., 2000). In rat model induced by BDL liver fibrosis, Cpd 861 improved hepatic fibrosis by decreasing the level of MMP-2, ski-related novel protein N (SnoN), transiently increasing the enzymatic activities of MMP-2, activating bone morphogenetic protein 7 (BMP-7)/Smad signaling pathway and inhibiting TGF-β1/Smad signaling pathway (Zhu et al., 2002; Hou et al., 2016; Chi et al., 2018). A randomized, double blind, placebo controlled clinical trial showed that liver fibrosis and early cirrhosis in patients with HBV infection could definitely be reversed by Cpd 861 after 24 weeks of treatment (Yin et al., 2004). Table 1 Anti hepatic fibrosis herbal formula of TCM introduced in this paper, contents and duplicated herbs in herbal formula Herbal Formula YCHD XYXD

XCHT

YGJ

HQD

DHZC

Content/ Chinese name (Latin name) Yinchenhao(Artemisia capillaris Thunb), Zhizi (Gardenia jasminoides J. Ellis), and Dahuang (Rheum officinale Baill) Dahuang (Rheum officinale Baill), Taoren (Semen Persicae), and Zhechong (Eupolyphaga Seu Steleophaga) Chaihu (Bupleurum chinense DC.), Huangqin (Scutellaria baicalensis Georgi), Renshen (Panax ginseng C.A. Mey), Banxia (Pinellia ternate (Thunb.) Makino), Shengjiang (Zingiber officinale Roscoe), Dazao (Ziziphus Jujuba Mill), Gancao (Glycyrrhiza uralensis Fisch) Beishashen (Adenophora stricta Miq), Shengdi (Rehmannia angulata (Oliv.) Hemsl.), Maidong (Ophiopogon japonicus (Thunb.) Ker Gawl.), Danggui (Angelica sinensis (Oliv.) Diels), Gouqizi (Lycium barbarum L.), Chuanlianzi (Melia toosendan Siebold & Zucc.) Huangqi (Astragalus aaronii (Eig) Zohary) and Gancao (Glycyrrhiza uralensis Fisch) Dahuang (Rheum officinale Baill), Zhechong (Eupolyphaga Seu Steleophaga), Huangqin (Scutellaria baicalensis Georgi), Gancao (Glycyrrhiza uralensis Fisch),Taoren (Prunus persica (L.) Batsch), Xingren (Prunus armeniaca L.), Baishao (Paeonia Lactiflora Pall.), Shengdi (Rehmannia angulata (Oliv.) Hemsl.), Ganqi (Resina Toxicodendri), Mengchong (Tabanus bivittatus Matsumura), Shuizhi (Whitmania pigra Whitman), Qicao (Holotrichia)

Duplicated herbs in ten herbal formula 1. Dahuang (Rheum officinale Baill) ( YCHD, XYXD, DHZC, ALHX); 2. Chaihu (Bupleurum chinense DC.) (XCHT, Cpd861); 3. Huangqin (Scutellaria baicalensis Georgi) (XCHT, DHZC); 4. Taoren (Semen Persicae) ( XYXD, DHZC, FZHY); 5. Zhechong (Eupolyphaga Seu Steleophaga) (XYXD, DHZC); 6. Shuizhi (Whitmania pigra Whitman) (DHZC, ALHX); 7. Danshen (Salvia miltiorrhiza Bunge) (FZHY, Cpd861, ); 8. Sanqi (Panax

13

FZHY

FFBJRG

ALHX

Cpd861

Taoren (Prunus persica (L.) Batsch), Dongchongxiacao (Cordyceps sinensis (Berk.) Sacc), Jiaogulan (Gynostemma aggregatum C.Y.Wu & S.K.Chen), Danshen (Salvia miltiorrhiza Bunge), Songhuafen (Pollen Pini) and Wuweizi (Schisandra chinensis (Turcz.) Baill.). Biejia (Carapax trionycis), Ezhu (Rhizoma curcumae), Chishao (Paeonia Lactiflora Pall.), Danggui (Angelica sinensis (Oliv.) Diels), Sanqi (Panax notoginseng (Burkill) F.H.Chen), Dangshen (Codonopsis pilosula (Franch.) Nannf.), Huangqi (Scutellaria baicalensis Georgi), Ziheche (Placenta hominis), Dongchongxiacao (Cordyceps sinensis (Berk.) Sacc), Banlangen (Isatis indigotica Fortune ex Lindl.), Lianqiao (Forsythia suspensa (Thunb.) Vahl). Guiban (Shell of Chinemys reevesii (Gray)), Biejia (Shell of Trinyx sinensis Widgmann), Shengdi (Rehmannia angulata (Oliv.) Hemsl.), Sanqi (Panax notoginseng (Burkill) F.H.Chen), Shuizhi (Whitmania pigra Whitman), Dilong (Pheretima aspergillum (E. Perrier), Jiangcan (Bombyx mori Linnaeus), Baizhu (Atractylodes macrocephala Koidz.), Yujin (Curcuma wenyujin Y.H.Chen & C.Ling), Niuhuang (Bezoar), Dahuang (Rheum officinale Baill) and Shuiniujiao (horn of Bubalus bubalis Linnaeus) Danshen (Salvia miltiorrhiza Bunge), Huangqi (Scutellaria baicalensis Georgi), Chaihu (Bupleurum chinense DC.), Jixueteng (Spatholobus suberectus Dunn), Chuanxiong (Ligusticum chuanxiong), Xiangfu (Cyperus rotundus L.), Chishao (Paeonia Lactiflora Pall.), Chenpi (Citrus reticulata Blanco), Danggui (Angelica sinensis (Oliv.) Diels), and Honghua (Carthamus tinctorius L.)

9.

10.

11.

12.

13.

14.

15.

notoginseng (Burkill) F.H.Chen) (FFBJRG, ALHX); Chishao (Paeonia Lactiflora Pall.) (FFBJRG, Cpd861); Shengdi (Rehmannia angulata (Oliv.) Hemsl.) (YGJ, DHZC, ALHX); Danggui (Angelica sinensis (Oliv.) Diels) (YGJ, FFBJRG, Cpd861); Huangqi (Astragalus aaronii (Eig) Zohary) (HQD, FFBJRG, Cpd861); Dongchongxiacao (Cordyceps sinensis (Berk.) Sacc) (FZHY, FFBJRG); Gancao (Glycyrrhiza uralensis Fisch) (XCHT, HQD, DHZC); Biejia (Carapax trionycis) (FFBJRG, ALHX).

We introduced these ten herbal formulae based on the following guidelines. First, ancient herbal formulae that have wide application and definite curative effect, such as YCHD, XYXD, XCHT, YGJ, HQD and DHZC; Second, modern herbal formulae with definite curative effect and approved by the CFDA, such as FZHY, FFBJRG, ALHX. Though Cpd861 does not belong to the two categories above, it obtained a national invention patent and has been proved to be clinically effective. Unfortunately, though there has been progress in animal model research and accumulative clinical experience of using YCHD and XYXD to treat patients with liver fibrosis, there is still a shortage of multicenter, randomized, double-blind, placebo-controlled clinical trial of YCHD and XYXD in such patients. In addition, some clinical trials did not strictly follow the principle of randomized control, which resulted in the decline of 14

reliability in their trial results. Kong et al. came to the conclusion that the clinical efficacy of XCHT in the treatment of chronic hepatitis B is still unclear due to the trial’s small-size and low quality (Kong et al., 2019). The clinical application of the above herbal formulae and major literatures of liver fibrosis treatment are shown in Table 2. Table 2 Clinical application of herbal formulas of TCM for liver fibrosis treatment Herbal formula XCHT YGJ HQD

Patients Design 24 (not mentioned) 68 (Randomized) 70 (Randomized) 1212 (Meta analysis)

DHZC

94 (Randomized)

References

Chronic hepatitis C

48

Deng et al., 2011

active compensated liver cirrhosis

48

Duan et al., 2016

hepatitis B cirrhosis

48

Cheng et al. 2019

HBV-related liver fibrosis HBV-related liver fibrosis advanced schistosomiasis hepatocirrhosis

Wei et al., 2015 Zhang et al., 2012

52

Niu et al., 2011

24

Cheng et al., 2008

24

Chen et al., 2016

48

Zhang et al., 2014

96

Xiao et al., 2014

180 (Randomized)

24

Deng et al., 2013

110 (Randomized)

48

Tian et al., 2013

24

Tang et al., 2012

24

Hu et al., 2006

24

Liu et al., 2005

12

Liu et al., 1998

96

Yang et al., 2016

48

Wu et al., 2014

24

Chen et al., 2007

49 (not mentioned) 180 (Randomized) 100 (not mentioned) 181 (Randomized)

FFBJRG

Duration (wk)

24

62 (Randomized)

FZHY

Diseases

80 (Randomized) 50 (Randomized) 216 (Randomized) 95 (not mentioned) 197 (not mentioned) 163 (not mentioned) 420 (Randomized)

HCV-related liver cirrosis HCV-related liver fibrosis liver cirrhosis patients

HBV-related liver fibrosis

HBV-related liver fibrosis

15

ALHX Cpd861

219 (Randomized) 72 (Randomized) 102 (Randomized)

HBV-related liver fibrosis HBV-related fibrosis and early cirrhosis

78

Miao et al., 2019

48

Jiang et al., 2012

24

Yin et al., 2004

Other herbal formulae, such as Heluoshugan Capsule, Biejiajian Pills and Qianggan capsule, as well as many self-made prescriptions, are not included in this review due to insufficient recent data and limited clinical applications.

3. Treatment of liver fibrosis patients with different TCM syndromes by different herbal formulae Unlike Western Medicine, TCM strictly relies on the two therapeutic pillars: holism and syndrome differentiation (Zhang et al., 2014). TCM practitioners classify biomedical maladjustments into different syndromes and each syndrome has its own suitable treatment protocol. The syndrome classification-based individualized therapy is commonly applied in the TCM practice for 3,000 years (Song et al., 2012; Jiang, 2005). We have sufficient reasons to believe that liver fibrosis patients with different TCM syndromes should be treated with different herbal formulae. YCHD is commonly used to treat liver fibrosis patients with damp heat syndrome of liver and gallbladder which exhibits symptoms including jaundice, distending pain of rib side, fatigue, loss of appetite, nausea caused by greasy food, self heating or cold and hot exchanges, abdomen distension, irregular stool, enlargement of liver or spleen, yellower urine and less urine, bitter mouth and dry mouth, red tongue, yellow and greasy coat of tongue, and string-like pulse or rapid pulse (Cai et al., 2019; Xie et al., 2018). XYXD is used to treat liver fibrosis patients with blood stasis blocking collateral, shown through Needle-pricking sensation and pain, dark face, dark tongue, and fine and sluggish pulse (Ma et al., 2017; Xie et al., 2018). YGJ is used to treat liver fibrosis patients with gan-yin deficiency syndrome with symptoms like dry throat, dry mouth, red tongue, little body fluid and weak pulse (Tao et al., 2009). XYXD and YGJ are capable of treating liver fibrosis at different stages during CCl4 induced liver cirrhosis formation in rats. XYXD can effectively treat major pathological changes, including rapid hyperplasia of hepatic fibrous connective tissue, obstruction of collaterals by blood stasis, and induced reconstruction of tissue structure. YGJ, with its Yin-nourishing action, is efficient in treating Gan-yin deficiency syndrome, which is a more severe injury of liver parenchyma occurring at 16

a later stage (Mu et al., 2006). DHZC could promote blood circulation, dredge channels and relieve oppression (Cai et al., 2010). FZHY helps boost essence supplementing deficiency and the efficiency on subjects with liver-kidney yin deficiency syndrome for patients who exhibit dry eyes and throat, feverish sensation in the chest and palms, lumbar debility, scanty coating on the tongue, and fine and rapid pulse (Sun et al., 2012; Song et al., 2018). With Chinese medical effects of softening hard masses and removing stagnation, dissolving blood stasis and detoxification, reinforcing qi and nourishing blood, FFBJRG can be used in treating liver fibrosis patients who have TCM syndrome of weakening of both qi and blood and blockage of meridians by blood stasis (Yang et al., 2016; Qu et al., 2014). It is worth noting that changes in syndromes may occur in patients with liver fibrosis during the treatment process, and different herbal formulae need to be used according to the corresponding TCM syndrome to achieve the best therapeutic effect. 4. Conclusion and future perspectives TCM has a history of thousands of years in the treatment of liver and gall diseases, but there is no medical term of liver fibrosis in TCM and only recent decades did relevant research emerge. Liver fibrosis patients with different syndromes need to be treated with different herbal formulae, which increase the difficulty of clinical efficacy research. Although YCHD and XYXD introduced in this paper have been used for thousands of years in clinical practice, the curative effect of chronic liver disease has NOT been fully affirmed. Despite many clinical research materials published, it is difficult to draw the research conclusions due to lack of strictly-followed principles of randomized and controlled design. Therefore, the clinical research literatures of YCHD and XYXD are not included in this paper, and only the literatures of studying mechanism in animal model of liver fibrosis are. XCHT, YGJ and HQD are also classic herbal formula with a long history of application with clinical trials conducted obliging to principles of random and control. However, larger sample of randomized controlled clinical studies are needed to further determine the efficacy of such herbal formulae. In contrast, most modern herbal formulae had a number of randomized and controlled clinical trials and obtained a more reliable basis for clinical efficacy. In particular, the FZHY and ALHX have recently published the research results on the treatment of patients with 17

chronic hepatitis B liver fibrosis or cirrhosis with entecavir. Compared to anti-viral treatment with entecavir alone, this method has improved the reversion rate of liver fibrosis; however, it is still deficient without syndrome classification therapy of TCM. TCM herbal formulae have a good prospect in treating liver fibrosis, but its composition of multiple drugs and a wide range of targets intensify the difficulty of studying their anti-hepatic mechanisms. Future research needs to further study the anti-hepatic mechanisms and select corresponding TCM herbal formula to treat patients with different syndromes of liver fibrosis or the same patient with different syndromes at different stages to achieve better curative results.

Acknowledgement This work was supported by Sichuan Science and Technology Program (No. 2018SZ0401, No. 2017FZ0052 and 2016FZ0093). Thank Miao Long for proofreading this manuscript.

References Amagaya, S., Hayakawa, M., Ogihara, Y., Ohta, Y., Fujiwara, K., Oka, H., Oshio, H., Kishi, T., 1989. Treatment of chronic liver injury in mice by oral administration of xiao-chai-hu-tang. J. Ethnopharmacol. 25, 181-187. Bian, Y.Q., Ning, B.B., Cao, H.Y., Lu, Y., Liu, C., Chen, G.F., Liu, J., Liu, P., Sun, M.Y., 2012. Formula-syndrome correlation study of three classical anti-jaundice formulas in inhibition of liver fibrosis induced by dimethylnitrosamine in rats. Zhong. Xi. Yi. Jie. He. Xue. Bao. 10, 1405-1412. Cai, F.F., Bian, Y.Q., Wu, R., Sun, Y., Chen, X.L., Yang, M.D., Zhang, Q.R., Hu, Y., Sun, M.Y., Su, S.B., 2019. Yinchenhao decoction suppresses rat liver fibrosis involved in an apoptosis regulation mechanism based on network pharmacology and transcriptomic analysis. Biomed. Pharmacother. 114, 108863. Cai, H., Song, Y.H., Xia, W.J., Jin, M.W., 2006. Aqueous extract of Yin-Chen-Hao decoction, a traditional Chinese prescription, exerts protectiveeffects on concanavalin A-induced hepatitis i n mice through inhibition of NF-kappaB. J. Pharm. Pharmacol. 58, 677-684. Cai, F.F., Wu, R., Song, Y.N., Xiong, A.Z., Chen, X.L., Yang, M.D., Yang, L., Hu, Y., Sun, M.Y., Su, S.B., 2018. Yinchenhao Decoction Alleviates Liver Fibrosis by Regulating Bile Acid Metabolism and TGF-β/Smad/ERK Signalling Pathway. Sci. Rep. 8, 15367. Cai, H.B., Sun, X.G., Liu, Z.F., Liu, Y.W., Tang, J., Liu, Q., Ji, B.M., Song, Y.H., Zhou, Y.C., Yang, M.H., Lv, Z.P., 2010. Effects of dahuangzhechong pills on cytokines and mitogen activated protein kinase activation in rats with hepatic fibrosis. J. Ethnopharmacol. 132, 157-164. 18

Chen, M.H., Chen, J.C., Tsai, C.C., Wang, W.C., Chang, D.C., Lin, C.C., Hsieh, H.Y., 2004. Sho-saiko-to prevents liver fibrosis induced by bile duct ligation in rats. Am. J. Chin. Med. 32, 195-207. Chen, M.H., Chen, J.C., Tsai, CC., Wang, W.C., Chang, D.C., Tu, D.G., Hsieh, H.Y., 2005. The role of TGF-beta 1 and cytokines in the modulation of liver fibrosis by Sho-saiko-to in rat's bile duct ligated model. J. Ethnopharmacol. 97, 7-13. Chen, Q., Wu, F., Wang, M., Dong, S., Liu, Y., Lu, Y., Song, Y., Zhou, Q., Liu, P., Luo, Y., Su, S., 2016. Transcriptional Profiling and miRNA-Target Network Analysis Identify Potential Biomarkers for Efficacy Evaluation of Fuzheng-Huayu Formula-Treated Hepatitis B Caused Liver Cirrhosis. Int. J. Mol. Sci. 17, pii: E883. Chen, Q.L., Lu, Y.Y., Peng, J.H., Dong, S., Wei, B., Song, Y.N., Zhou, Q.M., Zhang, H., Liu, P., Su, S.B., 2015. Dynamical Regulation Analysis Identifies Molecular Mechanisms of Fuzheng-Huayu Formula against Hepatitis B-Caused Liver Cirrhosis. Evid. Based. Complement. Alternat. Med. 2015, 238495. Chen, H., Yang, B.W., Yuan, M., Tang, H., Bai, L., Liu, C., He, M., Wang, L.C., 2016. Prevention and Therapeutic Effects of Fuzheng Huayu Capsule on Liver Fibrosis and Expression of Connective Tissue Growth Factor in Rats. Sichuan. Da. Xue. Xue. Bao. Yi. Xue. Ban. 47, 197-202. Chen, J.M., Yang, Y.P., Chen, D.Y., Han, J., Jin, X.Y., Huang, Z.X., Xu, C.B., Shen, Y.M., 2007. Efficacy and safety of Fufang Biejia Ruangan tablet in patients with chronic hepatitis B complicated with hepatic fibrosis. Zhonghua. Shi. Yan. He. Lin. Chuang. Bing. Du. Xue. Za. Zhi. 21, 358-360. Cheng, Y., Liu, P., Hou, T.L., Maimaitisidike, M., Ababaikeli, R., Abudureyimu, A., 2019. Mechanisms of Huangqi Decoction Granules on Hepatitis B Cirrhosis Patients Based on RNA-Sequencing. Chin. J. Integr. Med. 25, 507-514. Cheng, M.H., Pan, Z.H., Rao, G.H., Xu, J.H., Zhang, F., Chen, W.Z., Mo, C.J., 2008. Evaluation of hepatocellular function influenced by Chinese drug Dahuang Zhechong pill. Zhongguo. Zhong. Yao. Za. Zhi. 33, 564-566. Cheung, K.F., Ye, D.W., Yang, Z.F., Lu, L., Liu, C.H., Wang, X.L., Poon, R.T., Tong, Y., Liu, P., Chen, Y.C., Lau, G.K., 2009. Therapeutic efficacy of Traditional Chinese Medicine 319 recipe on hepatic fibrosis induced by carbon tetrachloride in rats. J. Ethnopharmacol. 124, 142-150. Cheng, Q., Li, N., Chen, M., Zheng, J., Qian, Z., Wang, X., Huang, C., Li, Q., Lin, Q., Shi, G., 2013. Fuzheng Huayu inhibits carbon tetrachloride-induced liver fibrosis in mice through activating hepatic NK cells. J. Ethnopharmacol.145, 175-181. Chi, C., Liu, X.Y., Hou, F., Yu, X.Z., Li, C.Y., Cui, L.J., Liu, R.X., Yin, C.H., 2018. Herbal compound 861 prevents hepatic fibrosis by inhibiting the TGF-β1/Smad/SnoN pathway in bile duct-ligated rats. BMC. Complement. Altern. Med. 18, 52. 19

Deng, G., Kurtz, R.C., Vickers, A., Lau, N., Yeung, K.S., Shia, J., Cassileth, B., 2011. A single arm phase II study of Far-Eastern traditional herbal formulation (sho-sai-ko-to or xiao-chai-hu-tang) in chronic hepatitis C patients. J. Ethnopharmacol. 136, 83-87. Deng, X., Liang, J., Liu, Z.W., Wu, F.S., Li, X., 2013. Treatment of posthepatitic cirrhosis by Fuzheng Huayu Tablet for reinforcing qi and resolving stasis. Chin. J. Integr. Med. 19, 289-296. Ding, H.G., Tang, S.Z., Wang, B.E., Jia, J.D., Zhao, C.H., 2003. Effects of herbal compound 861 on hepatic stellate cell expressing endothelin-1 protein and mRNA. Zhonghua. Gan. Zang. Bing. Za. Zhi. 11, 308. Dong, S., Chen, Q.L., Su, S.B., 2015. Curative Effects of Fuzheng Huayu on Liver Fibrosis and Cirrhosis: A Meta-Analysis. Evid. Based. Complement. Alternat. Med. 2015, 125659. Dong, S., Cai, F.F., Chen, Q.L., Song, Y.N., Sun, Y., Wei, B., Li, X.Y., Hu, Y.Y., Liu, P., Su, S,B., 2018. Chinese herbal formula Fuzheng Huayu alleviates CCl4-induced liver fibrosis in rats: a transcriptomic and proteomic analysis. Acta. Pharmacol. Sin. 39, 930-941. Du, J.X., Liu, P., Sun, M.Y., Tao, Q., Zhang, L.J., Chen, G.F., Hu, Y.Y., Liu, C.H., Xu, L.M., 2011. Chinese herbal medicine Xiayuxue Decoction inhibits liver angiogenesis in rats with carbon tetrachloride-induced liver fibrosis. Zhong. Xi. Yi. Jie. He. Xue. Bao. 9, 878-887. Du, J.X., Sun, M.Y., Du, G.L., Li, F.H., Liu, C., Mu, Y.P., Chen, G.F., Long, A.H., Bian, Y.Q., Liu, J., Liu, C.H., Hu, Y.Y., Xu, L.M., Liu, P., 2012. Ingredients of Huangqi decoction slow biliary fibrosis progression by inhibiting the activation of the transforming growth factor-beta signaling pathway. BMC. Complement. Altern. Med. 12, 33. Du, J.X., Qiu, B.F., Liu, P., Sun, M.Y., Chen, G.F., Liu, J., 2010. Huangqi decoction inhibits cholangiocyte proliferation and transdifferentiation in cholestatic liver fibrosis induced by BDL in rats. Zhonghua. Gan. Zang. Bing. Za. Zhi. 18, 13-18. Duan, S.H., Bao, Z.Y., Yuan, X.D., Wang, L., Liu, M.S., 2016. Efficacy Observation of Yiguanjian DecoctionCombined Adefovir Dipivoxil Tablet in Treating HBeAg Negative Chronic Viral Hepatitis B Active Compensated Liver Cirrhosis Patients. Zhongguo. Zhong. Xi. Yi. Jie. He. Za. Zhi. 36, 535-538. Ebrahimi, H., Naderian, M., Sohrabpour, A.A., 2018. New Concepts on Reversibility and Targeting of Liver Fibrosis; A Review Article. Middle. East. J. Dig. Dis. 10, 133-148. Friedman, S.L., 2015. Hepatic Fibrosis: Emerging Therapies. Dig. Dis. 33, 504-507. Gao, G.Y., Zheng, X.Y., Peng, Y., Tao, Y.Y., Liu, P., Yang, T., Liu, C.H., 2016. Effect of Fuzheng Huayu capsule on serum metabolomics in rats with liver fibrosis induced by dimethylnitrosamine. Zhongguo. Zhong. Yao. Za. Zhi. 41, 1725-1731. Ge, X.J., Zhao, C.Q., Xu, L.M., 2017. Effect of Fuzheng Huayu capsules on survival rate of patients with liver cirrhosis. Zhonghua. Gan. Zang. Bing. Za. Zhi. 25, 834-840. Gong, Z., Lin, J., Zheng, J., Wei, L., Liu, L., Peng, Y., Liang, W., Hu, G. 2019. Dahuang Zhechong 20

pill attenuates CCl4-induced rat liver fibrosis via the PI3K-Akt signaling pathway. J. Cell. Biochem. Sep 9. doi: 10.1002/jcb.29378. Gou, X., Tao, Q., Feng, Q., Peng, J., Zhao, Y., Dai, J., Wang, W., Zhang, Y., Hu, Y., Liu P., 2013. Urine metabolic profile changes of CCl4-liver fibrosis in rats and intervention effects of Yi Guan Jian Decoction using metabonomic approach. BMC. Complement. Altern. Med. 13, 123. Gu, J., Zhang, Q., Xue, D., Cai, H., Xu, L., 2013. A randomized controlled study of fuzheng huayu capsule for prevention of esophageal variceal bleeding in patients with liver cirrhosis. Evid. Based. Complement. Alternat. Med. 2013, 534960. Guo, S.G., Zhang, W., Jiang, T., Dai, M., Zhang, L.F., Meng, Y.C., Zhao, L.Y., Niu, J.Z., 2004. Influence of serum collected from rat perfused with compound Biejiaruangan drug on hepatic stellate cells. World. J. Gastroenterol. 10, 1487-1494. Higashi, T., Friedman, S.L., Hoshida, Y., 2017. Hepatic stellate cells as key target in liver fibrosis. Adv. Drug. Deliv. Rev. 121, 27-42. Hong, M., Li, S., Tan, H.Y., Wang, N., Tsao, S.W., Feng, Y., 2015, Current Status of Herbal Medicines in Chronic Liver Disease Therapy: The Biological Effects, Molecular Targets and Future Prospects. Int. J. Mol. Sci. 16, 28705-28745. Hou, F., Liu, R., Liu, X., Cui, L., Wen, Y., Yan, S., Yin, C., 2016. Attenuation of liver fibrosis by herbal compound 861 via upregulation of BMP-7/Smad signaling in the bile duct ligation model rat. Mol. Med. Rep. 13, 4335-4342. Hu, R., Jia, W.Y., Xu, S.F., Zhu, Z.W., Xiao, Z., Yu, S.Y., Li, J., 2019. Xiaochaihutang Inhibits the Activation of Hepatic Stellate Cell Line T6 Through the Nrf2 Pathway. Front Pharmacol. 9, 1516. Hu, R., Jia, W.Y., Xu, S.F., Zhu, Z.W., Xiao, Z., Yu, S.Y., Li, J., 2018. Xiaochaihutang Inhibits the Activation of Hepatic Stellate Cell Line T6 Through the Nrf2 Pathway. Front. Pharmacol. 9, 1516. Hu, Y.Y., Liu, P., Liu, C., 2006. Investigation on indication of fuzheng huayu capsule against hepatic fibrosis and its non-invasive efficacy evaluation parameters: data analysis of liver biopsy of 50 patients with chronic hepatitis B before and after treatment. Zhongguo. Zhong. Xi. Yi. Jie. He. Za. Zhi. 26, 18-22. Hu, Y.Y., Liu, P., Liu, C., Liu, C.H., Xu, L.M., 2006. The value of serum markers in evaluating liver fibrotic changes. Zhonghua. Gan. Zang. Bing. Za. Zhi. 14, 174-177. Hu, X.Q., Song, Y.N., Wu, R., Cai, F.F., Zhang, Y., Peng, J.H., Hu, Y.Y., Su, S.B., 2019. Metabolic mechanisms of Fuzheng-Huayu formula against liver fibrosisin rats. J. Ethnopharmacol. 238, 111888. Huang, J., Huang, H., Jiao, Y., Ai, G., Huang, T., Li, L., Yu, H., Ma, K., Xiao, F., 2009. Effect of anluohuaxian tablet combined with gamma-IFN on schistosomal liver fibrosis. J. Huazhong. Univ. Sci. Technolog. Med. Sci. 29, 53-58. 21

Huang, L.W., Jiang, N., Ping, J., Zhang, J., Xu, L.M., 2019. Study on anti- fibrotic mechanism of Fuzheng -Huayu formula to suppress autophagy in mice. Zhonghua. Gan. Zang. Bing. Za. Zhi. 27, 621-627. Huang, C., Shen, D., Sun, S., Huang, Y., Xin, Y., Luo, H., Chen, Y., Zhou, Z., Liu, F., Chen, X., 2019. Effect of Fufang Biejia Ruangan Tablet on lowering biochemical and virological parameters of hepatic fibrosis in patients with chronic hepatitis B: Protocol for a systematic review and meta-analysis of randomized controlled trials and cohort studies. Medicine. (Baltimore). 98, e15297. Huang, J., Huang, H., Jiao, Y., Ai, G., Huang, T., Li, L., Yu, H., Ma, K., Xiao, F., 2009. Effect of anluohuaxian tablet combined with gamma-IFN on schistosomal liver fibrosis. J. Huazhong. Univ. Sci. Technolog. Med. Sci. 29, 53-58. Jia, Y.H., Wang, R.Q., Mi, H.M., Kong, L.B., Ren, W.G., Li, W.C., Zhao, S.X., Zhang, Y.G., Wu, W.J., Nan, Y.M., Yu, J., 2012. Fuzheng Huayu recipe prevents nutritional fibrosing steatohepatitis in mice. Lipids. Health. Dis. 11, 45. Jiang, S.L., Hu, X.D., Liu, P., 2015. Immunomodulation and liver protection of Yinchenhao decoction against concanavalin A-induced chronic liver injury in mice. J. Integr. Med. 13, 262-268. Jiang, Y.F., Ma, J., He, B., Li, N.P., Tang, W., Gong, G.Z., 2012. The therapeutic effect of Anluohuaxian capsule combined with adefovir dipivoxil on patients with chronic hepatitis B and influence on hepatic histology. Zhonghua. Gan. Zang. Bing. Za. Zhi. 20, 344-347. Jiang, W.Y., 2005. Therapeutic wisdom in traditional Chinese medicine: perspective from modern science. Trends. Pharmacol. Sci. 26, 558-563. Kong Z, Liang N, Yang GL, Zhang Z, Liu Y, Li J, Liu X, Liang S, Nikolova D, Jakobsen JC, Gluud C, Liu JP. 2019. Xiao Chai Hu Tang, a herbal medicine, for chronic hepatitis B. Cochrane. Database. Syst. Rev. 2019(11). Kusunose, M., Qiu, B., Cui, T., Hamada, A., Yoshioka, S., Ono, M., Miyamura, M., Kyotani, S., Nishioka, Y., 2002. Effect of Sho-saiko-to extract on hepatic inflammation and fibrosis in dimethylnitrosamine induced liver injury rats. Biol. Pharm. Bull. 25, 1417-1421. Lam, P., Cheung, F., Tan, H.Y., Wang, N., Yuen, M.F., Feng, Y., 2016. Hepatoprotective Effects of Chinese Medicinal Herbs: A Focus on Anti-Inflammatory and Anti-Oxidative Activities. Int. J. Mol. Sci. 17, 465-501. Lee, T.Y., Chang, H.H., Chen, J.H., Hsueh, M.L., Kuo, J.J., 2007. Herb medicine Yin-Chen-Hao-Tang ameliorates hepatic fibrosis in bile duct ligation rats. J. Ethnopharmacol. 109, 318-324. Lee, T.Y., Chang, H.H., Wu, M.Y., Lin, H.C., 2007. Yin-Chen-Hao-Tang ameliorates obstruction-induced hepatic apoptosis in rats. J. Pharm. Pharmacol. 59, 583-590. Lee, T.Y., Chang, H.H., Kuo, J.J., Shen, J.J., 2009. Changes of hepatic proteome in bile duct ligated rats with hepatic fibrosis following treatment with Yin-Chen-Hao-Tang. Int. J. Mol. 22

Med. 23, 477-484. Lee, J.K., Kim, J.H., Shin, H.K., 2011. Therapeutic effects of the oriental herbal medicine Sho-saiko-to on liver cirrhosis and carcinoma. Hepatol. Res. 41, 825-837. Li, J., Hu, R., Xu, S., Li, Y., Qin, Y., Wu, Q., Xiao, Z., 2017. Xiaochaihutang attenuates liver fibrosis by activation of Nrf2 pathway in rats. Biomed. Pharmacother. 96, 847-853. Li, W.K., Wang, G.F., Wang, T.M., Li, Y.Y., Li, Y.F., Lu, X.Y., Wang, Y.H., Zhang, H., Liu, P., Wu, J.S., Ma, Y.M., 2019. Protective effect of herbal medicine Huangqi decoction against chronic cholestatic liver injury by inhibiting bile acid-stimulated inflammation in DDC-induced mice. Phytomedicine. 62, 152948. Li, L., Xu, M., Liu, Z.L., 2003. Effect of dahuang zhechong pill on transforming growth factor-beta 1 in hepatic stellate cells in rats. Zhongguo. Zhong. Xi. Yi. Jie. He. Za. Zhi. 23, 763-766. Lin, H.J., Chen, J.Y., Lin, C.F., Kao, S.T., Cheng, J.C., Chen, H.L., Chen, C.M., 2011. Hepatoprotective effects of Yi Guan Jian, an herbal medicine, in rats with dimethylnitrosamine-induced liver fibrosis. J. Ethnopharmacol. 134, 953-960. Liu, C., Sun, M., Wang, L., Wang, G., Chen, G., Liu, C., Liu, P., 2008. Effects of Yinchenhao Tang and related decoctions on DMN-induced cirrhosis/fibrosis in rats. Chin. Med. 3, 1. Liu, C., Sun, M., Yan, X., Han, L., Zhang, Y., Liu, C., El-Nezami, H., Liu, P., 2008. Inhibition of hepatic stellate cell activation following Yinchenhao decoction administration to dimethylnitrosamine-treated rats. Hepatol. Res. 3, 919-929. Liu, C., Liu, P., Tao, Q., 2010. Recipe-syndrome correlation and pathogenesis mechanism of Yinchenhao Decoction in intervening dimethylnitrosamine induced liver cirrhosis progress in rats. Zhongguo. Zhong. Xi. Yi. Jie. He. Za. Zhi. 30, 845-850. Liu, C., Yuan, X., Tao, L., Cheng, Z., Dai, X., Sheng, X., Xue, D., 2015. Xia-yu-xue decoction (XYXD) reduces carbon tetrachloride (CCl4)-induced liver fibrosis through inhibition hepatic stellate cell activation by targeting NF-κB and TGF-β1 signaling pathways. BMC. Complement. Altern. Med. 15, 201. Liu, C., Cai, J., Cheng, Z., Dai, X., Tao, L., Zhang, J., Xue, D., 2015. Xiayuxue decoction reduces renal injury by promoting macrophage apoptosis in hepatic cirrhotic rats. Genet. Mol. Res. 14, 10760-10773. Liu, C., Wang, G., Chen, G., Mu, Y., Zhang, L., Hu, X., Sun, M., Liu, C., Liu, P., 2012. Huangqi decoction inhibits apoptosis and fibrosis, but promotes Kupffer cell activation in dimethylnitrosamine-induced rat liver fibrosis. BMC. Complement. Altern. Med. 12, 51. Liu, P., Liu, C., Hu, Y.Y., 1996. Effect of fuzheng huayu recipe in treating posthepatitic cirrhosis. Zhongguo. Zhong. Xi. Yi. Jie. He. Za. Zhi. 16, 459-462. Liu, P., Liu, C., Xu, L.M., Hu, Y.Y., Xue, H.M., Liu, C.H., Zhang, Z.Q., 1998. Effects of Fuzheng Huayu 319 recipe on liver fibrosis in chronic hepatitis B. World. J. Gastroenterol. 4, 348-353. Liu, P., Hu, Y.Y., Liu, C., Xu, L.M., Liu, C.H., Sun, K.W., Hu, D.C., Yin, Y.K., Zhou, X.Q., Wan, 23

M.B., Cai, X., Zhang, Z.Q., Ye, J., Tang, B.Z., He, J., 2003. Multicenter clinical study about the action of Fuzheng Huayu Capsule against liver fibrosis with chronic hepatitis B. Zhong. Xi. Yi. Jie. He. Xue. Bao. 1, 89-98, 102. Liu, P., Hu, Y.Y., Liu, C., Xu, L.M., Liu, C.H., Sun, K.W., Hu, D.C., Yin, Y.K., Zhou, X.Q., Wan, M.B., Cai, X., Zhang, Z.Q., Ye, J., Zhou, R.X., He, J., Tang, B.Z., 2005. Multicenter clinical study on Fuzhenghuayu capsule against liver fibrosis due to chronic hepatitis B. World. J. Gastroenterol. 11, 2892-2899. Liu, Y., Liu, P., Wang, L., 2006. The effect of Fuzheng Huayu Decoction on the hepatic proteome during the formation and resolution of rat liver fibrosis. Zhonghua. Gan. Zang. Bing. Za. Zhi.14, 422-425. Liu, Y., Liu, P., Hu, Y.Y., Xu, L., Wang, L., Mu, Y., Du, G., 2006. Dynamic change of metabolism related protein in liver tissue of rats' model of hepatic fibrosis and regulatory effect of fuzheng huayu decoction on it. Zhongguo. Zhong. Xi. Yi. Jie. He. Za. Zhi. 26, 224-227. Liu, J., Wang, J.Y., Wei, L.M., Lu, Y., Jin, H., 2007. Effects of Fuzheng Huayu Decoction on plasma proteome in cirrhosis: preliminary experimental study with rats. Zhonghua. Yi. Xue. Za. Zhi. 87, 1272-1275. Liu, C., Chen, W., Liu, P., Wang, Z., Hu, Y., Liu, C., 2001. Changes of lipid peroxidation in liver fibrogenesis induced by dimethylnitrosamine and drugs' intervention. Zhonghua. Gan. Zang. Bing. Za. Zhi. 9 Suppl,18-20. Liu, C., Liu, P., Liu, C.H., Zhu, X.Q., Ji,G., 1998. Effects of Fuzhenghuayu decoction on collagen synthesis of cultured hepatic stellate cells, hepatocytes and fibroblasts in rats. World. J. Gastroenterol. 4, 548-549. Lu, W., Gao, Y.H., Wang, Z.Z., Cai, Y.S., Yang, Y.Q., Miao, Y.Q., Pei, F., Liu, X.E., Zhuang, H., 2017. Effects of Anluohuaxianwan on transforming growth factor-β1 and related signaling pathways in rats with carbon tetrachloride-induced liver fibrosis. Zhonghua. Gan. Zang. Bing. Za. Zhi. 25, 257-262. Luk, J.M., Wang, X., Liu, P., Wong, K.F., Chan, K.L., Tong, Y., Hui, C.K., Lau, G.K., Fan, S.T., 2007. Traditional Chinese herbal medicines for treatment of liver fibrosis and cancer: from laboratory discovery to clinical evaluation. Liver. Int. 27, 879-890. Ma, W., Tao, L., Zhang, W., Zhu, Y., Xue, D., Zhang, J., Liu, C., 2017. Xia-Yu-Xue Decoction Inhibits Intestinal Epithelial Cell Apoptosis in CCl4-Induced Liver Fibrosis. Cell. Physiol. Biochem. 44, 333-344. Miao, L., Yang, W.N., Dong, X.Q., Zhang, Z.Q., Xie, S.B., Zhang, D.Z., Zhang, X.Q., Cheng, J., Zhang, G., Zhao, W.F., Xie, Q., Liu, Y.X., Ma, A.L., Li, J., Shang, J., Bai, L., Cao, L.H., Zou, Z.Q., Li, J.B., Lyu, F.D., Liu, H., Wang, Z.J., Zhang, M.X., Chen, L.M., Liang, W.F., Gao, H., Zhuang, H., Zhao, H., Wang, G.Q., 2019. Combined anluohuaxianwan and entecavir treatment significantly improve the improvement rate of liver fibrosis in patients with chronic hepatitis B virus infection. Zhonghua. Gan. Zang. Bing. Za. Zhi. 27, 521-526. 24

Mu, Y.P., Liu, P., Long, A.H., 2006. Study on pathogenesis of CCl4 induced cirrhosis formation in rats based on the recipe used. Zhongguo. Zhong. Xi.Yi. Jie. He. Za. Zhi. 26, 344-347. Mu,Y., Liu, P., Du, G., Du, J., Wang, G., Long, A., Wang, L., Li, F., 2009. Action mechanism of Yi Guan Jian Decoction on CCl4 induced cirrhosis in rats. J. Ethnopharmacol. 121, 35-42. Niu, X.H., Wu, P.F., Hua, H.Y., Huang, L.H., Wu, H.Y., Zhu, H.Y., Yang, X.J., Yao, S.Z., Li, Y.G., Qiu, Y.W., 2011. Therapeutic effect of dahuangzhechong pills on advanced schistosomiasis. Zhongguo. Xue. Xi. Chong. Bing. Fang. Zhi. Za. Zhi. 23, 701-703. Pan, Z.H., Xie, Y., He, H.W., 2005. Effects of dahuang zhechong pill on expression and activity of matrix metalloproteinase in rats' hepatic stellate cells. Zhongguo. Zhong. Xi. Yi. Jie. He. Za. Zhi. 25, 1100-1103. Parola, M., Pinzani, M., 2019. Liver fibrosis: Pathophysiology, pathogenetic targets and clinical issues. Mol. Aspects. Med. 65, 37-55. Qiu, B.F., Du, J.X., Shen, D.Z., 2010. Mechanism of hepatocytes transdifferentiation to bile duct epithelial cells and intervention of huangqi decoction. Zhongguo. Zhong. Xi. Yi. Jie. He. Za. Zhi. 30, 513-518. Qu, J., Yu, Z., Li, Q., Chen, Y., Xiang, D., Tan, L., Lei, C., Bai, W., Li, H., Shang, Q., Chen, L., Hu, X., Lu, W., Li, Z., Chen, D., Wang, X., Zhang, C., Xiao, G., Qi, X., Chen, J., Zhou, L., Chen, G., Li, Y., Zeng, Z., Rong, G., Dong, Z., Chen, Y., Lou, M., Wang, C., Lu, Y., Zhang, C., Yang, Y., 2014. Blocking and reversing hepatic fibrosis in patients with chronic hepatitis B treated by traditional Chinese medicine (tablets of biejia ruangan or RGT): study protocol for a randomized controlled trial. Trials. 15, 438. Rowe, I.A., 2017. Lessons from Epidemiology: The Burden of Liver Disease. Dig. Dis. 35, 304-309. Sakaida, I., Hironaka, K., Kimura, T., Terai, S., Yamasaki, T., Okita, K., 2004. Herbal medicine Sho-saiko-to (TJ-9) increases expression matrix metalloproteinases (MMPs) with reduced expression of tissue inhibitor of metalloproteinases (TIMPs) in rat stellate cell. Life. Sci. 74, 2251-2263. Schuppan, D., Kim, Y.O., 2013. Evolving therapies for liver fibrosis. J. Clin. Invest. 123, 1887-1901. Shen, D.Z., Tao, Q., Du, J.X., Ding, S.D., Chen, G.F., Hu, Y.Y., Liu, P., 2010. Effects of Yiguanjian Decoction on liver cirrhosis formation: a differential proteomics study in rats. Zhong. Xi. Yi. Jie. He. Xue. Bao. 8, 158-167. Shimizu, I., Ma, Y.R., Mizobuchi, Y., Liu, F., Miura, T., Nakai, Y., Yasuda, M., Shiba, M., Horie, T., Amagaya, S., Kawada, N., Hori, H., Ito, S., 1999. Effects of Sho-saiko-to, a Japanese herbal medicine, on hepatic fibrosis in rats. Hepatology. 29, 149-160. Song, Y.N., Zhang, G.B., Lu, Y.Y., Chen, Q.L., Yang, L., Wang, Z.T., Liu, P., Su, S.B., 2016. Huangqi decoction alleviates dimethylnitrosamine-induced liver fibrosis: An analysis of bile acids metabolic mechanism. J. Ethnopharmacol. 189, 148-156. 25

Song, Y.N., Zhang, H., Guan, Y., Peng, J.H., Lu, Y.Y., Hu, Y.Y., Su, S.B., 2012. Classification of Traditional Chinese Medicine Syndromes in Patients with Chronic Hepatitis B by SELDI-Based ProteinChip Analysis. Evid. Based. Complement. Alternat. Med. 2012, 626320. Song,Y.N., Chen, J., Cai, F.F., Lu, Y.Y., Chen, Q.L., Zhang, Y.Y., Liu, P., Su, S.B., 2018. A metabolic mechanism analysis of Fuzheng-Huayu formula for improving liver cirrhosis with traditional Chinese medicine syndromes. Acta. Pharmacol. Sin. 39, 942-951. Stickel, F., Brinkhaus, B., Krähmer, N., Seitz, HK., Hahn, E.G., Schuppan, D., 2002. Antifibrotic properties of botanicals in chronic liver disease. Hepatogastroenterology. 49, 1102-1108. Sun, M.Y., Wang, L., Mu, Y.P., Liu, C., Bian, Y.Q., Wang, X.N., Liu, P., 2011. Effects of Chinese herbal medicine Yinchenhao Decoction on expressions of apoptosis-related genes in dimethylnitrosamine- or carbon tetrachloride-induced liver cirrhosis in rats. Zhong. Xi. Yi. Jie. He. Xue. Bao. 9, 423-434. Sun, S., Dai, J., Wang, W., Cao, H., Fang, J., Hu, Y.Y., Su, S., Zhang, Y., 2012. Metabonomic Evaluation of ZHENG Differentiation and Treatment by Fuzhenghuayu Tablet in Hepatitis-B-Caused Cirrhosis. Evid. Based. Complement. Alternat. Med. 2012, 453503. Takahashi, Y., Soejima, Y., Kumagai, A., Watanabe, M., Uozaki, H., Fukusato, T., 2014. Inhibitory effects of Japanese herbal medicines sho-saiko-to and juzen-taiho-to on nonalcoholic steatohepatitis in mice. PLoS One. 9, e87279. Tajiri, H., Kozaiwa, K., Ozaki, Y., Miki, K., Shimuzu, K., Okada, S., 1991. Effect of sho-saiko-to (xiao-chai-hu-tang) on HBeAg clearance in children with chronic hepatitis B virus infection and with sustained liver disease. Am J Chin Med. 19, 121-129. Tan, X.H., Li, C.Q., Zou, S.R., Xie, M., Zhang, A.M., Li, W.L., Li, X.Y., Huang, H.F., Lei, C.L., 2010. Inhibitory effect of anluohuaxianwan on experimental hepatic fibrosis in rats. Zhonghua. Gan. Zang. Bing. Za. Zhi. 18, 9-12. Tang, C.L., Zhou, Z., Shi, W.Q., 2012. Effects of Fuzheng Huayu Capsule on the ratio of TGF-beta1/BMP-7 of chronic viral hepatitis B fibrosis patients of Gan-Shen insufficiency blood-stasis obstruction syndrome. Zhongguo. Zhong. Xi. Yi. Jie. He. Za. Zhi. 32, 20-24. Tao, Q., Sun, M.Y., Feng, Q., 2009. Syndrome identification of CCl4 induced liver fibrosis model rats based on syndrome detecting from recipe used. Zhongguo. Zhong. Xi. Yi. Jie. He. Za. Zhi. 29, 246-250. Tao, Q., Wang, X.N., Mu, Y.P., Feng, Q., Peng, J.H., Liu, P., Fu, W.W., Zhang, W.M., Hu, Y.Y., 2012. Dynamic change of lipid peroxidation-related protein expression and the intervention effects of Yiguanjian decoction in a rat model of CCl4-induced liver fibrosis. Zhonghua. Gan. Zang. Bing. Za. Zhi. 20, 116-121. Tao, Y.Y., Yan, X.C., Zhou, T., Shen, L., Liu, Z.L., Liu, C.H., 2014. Fuzheng Huayu recipe alleviates hepatic fibrosis via inhibiting TNF-α induced hepatocyte apoptosis. BMC. Complement. Altern. Med. 14, 449. 26

Tian, M., Liu, W., You, H., Zhao, Q., Ouyang, L., Gao, B., Zhang, X., Che, N., 2016. Protective effect of Yiguanjian decoctionagainst DNA damage on concanavalin A-induced liver injury mice model. J. Tradit. Chin. Med. 36, 471-478. Tian, Y.L., Zhu, X.Y., Yin, W.W., Zang, Z.D., Wang, L., Fu, X.L., 2013. Supplemental Fuzhenghuayu capsule therapy for improving liver fibrosis markers in patients with chronic hepatitis B following unsatisfactory outcome of nucleos(t)ide analogue monotherapy. Zhonghua. Gan. Zang. Bing. Za. Zhi. 21, 514-518. Wang, X., Wang, N., Cheung, F., Lao, L., Li, C., Feng, Y., 2015. Chinese medicines for prevention and treatment of human hepatocellular carcinoma: currentpro gress on pharmacological actions and mechanisms. J. Integr. Med. 13, 142-164. Wang, F.Y., Tang, X.D., Xu, Y.G., 2008. Effect of ronggan mixture on cell apoptosis in rats with chronic immune liver injury induced by concanavalin A. Zhongguo. Zhong. Xi. Yi. Jie. He. Za. Zhi. 28, 835-838. Wang, B., Sun, M.Y., Long, A.H., Cao, H.Y., Ren, S., Bian, Y.Q., Lu, X., Gu, H.T., Liu, C.H., Liu, P., 2015. Yin-Chen-Hao-Tang alleviates biliary obstructive cirrhosis in rats by inhibiting biliary epithelial cell proliferation and activation. Pharmacogn. Mag. 11, 417-425. Wang, Y.H., Zhao, C.X., Chen, B.M., He, M., Liu, L.Q., Li, C.Y., Chen, X., 2014. Reverse effect of Yinchenhao decoction in dimethyl nitrosamine-induced hepatic fibrosis in rats. Zhongguo. Zhong. Yao. Za. Zhi. 39, 1473-1478. Wang, X.L., Jia, D.W., Liu, H.Y., Yan, X.F., Ye, T.J., Hu, X.D., Li, B.Q., Chen, Y.L., Liu, P., 2012. Effect of Yiguanjian decoction on cell differentiation and proliferation in CCl₄-treated mice. World. J. Gastroenterol. 18, 3235-3249. Wang, X.N., Tao, Q., Feng, Q., Peng, J.H., Liu, P., Hu, Y.Y., 2011. Effects of Chinese herbal medicine Yiguanjian Decoction on collagen metabolism of hepatic tissues in rats with CCl4-induced liver fibrosis. Zhong. Xi. Yi. Jie. He. Xue. Bao. 9, 651-657. Wang, L., Liu, P., Wang, C.S., 2008. Effects of 5 classical recipes on anti-oxidative stress in rat liver with cirrhosis. Zhongguo. Zhong. Xi. Yi. Jie. He. Za. Zhi. 28, 435-439. Wang, J., Peng, F.C., 2018. Meta-analysis on indirect comparison of Fuzheng Huayu Jiaonang and Anluo Huaxian Wan in treatment of chronic hepatitis B with liver fibrosis. Zhongguo. Zhong. Yao. Za. Zhi. 43, 1492-1500. Wang, T., Zhou, X., Liu, H., Wang, J., Zhang, P., Zhu, Y., Li, K., Wei, S., Li, H., Wang, L., Wang, R., Zhao, Y., 2018. Fuzheng Huayu capsule as an adjuvant treatment for HBV-related cirrhosis: A systematic review and meta-analysis. Phytother. Res. 32, 757-768. Wang, L., Yan, X., Zeng, Z., Lv, J., Liu, P., Liu, C., 2010. Effect of fuzheng huayu recipe and huangqi tang on DMN-induced experimental liver cirrhosis in rats. Zhongguo. Zhong. Yao. Za. Zhi. 35, 1740-1744. Wang, Q.L., Tao, Y.Y., Shen, L., Cui, H.Y., Liu, C.H., 2012. Chinese herbal medicine Fuzheng Huayu recipe inhibits liver fibrosisby mediating the transforming growth factor-β1/Smads 27

signaling pathway. Zhong. Xi. Yi. Jie. He. Xue. Bao. 10, 561-568. Wang, R.Q., Mi, H.M., Li, H., Zhao, S.X., Jia, Y.H., Nan, Y.M., 2015. Modulation of IKKβ/NF-κB and TGF-β1/Smad via Fuzheng Huayu recipe involves in prevention of nutritional steatohepatitis and fibrosis in mice. Iran. J. Basic. Med. Sci. 18, 404-411. Wang, L., Wang, J., Wang, B.E., Xiao, P.G., Qiao, Y.J., Tan, X.H., 2004. Effects of herbal compound 861 on human hepatic stellate cell proliferation and activation. World. J. Gastroenterol. 10, 2831-2835. Wang, L., Wang, B.E., Wang, J., Xiao, P.G., Tan, X.H., 2008. Herbal compound 861 regulates mRNA expression of collagen synthesis- and degradation-related genes in human hepatic stellate cells. World. J. Gastroenterol. 14, 1790-1794. Wang, L., Lu, W., Gao, Y.H., Cao, X., Pei, F., Liu, X.E., Zhuang, H., 2019. Effect of Anluohuaxianwan on the expression of matrix metalloproteinases and their inhibitors in rat liver with fibrosis. Zhonghua. Gan. Zang. Bing. Za. Zhi. 27, 267-273. Wei, F., Lang, Y., Gong, D., Fan, Y., 2015. Effect of Dahuang zhechong formula on liver fibrosis in patients with chronic hepatitis B: a meta-analysis. Complement. Ther. Med. 23, 129-138. Wu, L., Zhou, P.Q., Xie, J.W., Zhu, R., Zhou, S,C., Wang, G., Wu, Z.X., Hao, S., 2015. Effects of Yinchenhao decoction on self-regulation of renin-angiotensin system by targeting angiotensin converting enzyme 2 in bile duct-ligated rat liver. J. Huazhong. Univ. Sci. Technolog. Med. Sci. 35, 519-524. Wu, B.R., Zheng, Y.L., Sang, X.L., Jin, M., Wang, W.Z., Zhang, Q.S., Zhao, S.X., Kong, L., 2013. Role of the IGF-1/PI3K pathway and the molecular mechanism of Fuzhenghuayu therapy in a spontaneous recovery rat model of liver fibrosis. Zhonghua. Gan. Zang. Bing. Za. Zhi. 21, 674-678. Wu, G., He, H., Li, H., Chen, W., 2014. Clinical effect of combination therapy with Fufang Biejia Ruangan tablet and entecavir in patients with hepatitis B virus-related cirrhosis. Zhonghua. Gan. Zang. Bing. Za. Zhi. 22, 604-608. Xiao, D., Gu, J., Cai, H., Zhang, Q., Xue, D., Zhao, C., Xu, L., 2014. A randomized placebo-controlled multicentre study of Fuzhenghuayucapsule for prevention of oesophageal variceal bleeding in patients with liver cirrhosis. Zhonghua. Gan. Zang. Bing. Za. Zhi. 22, 594-599. Xie, H., Tao, Y., Lv, J., Liu, P., Liu, C., 2013. Proteomic analysis of the effect of fuzheng huayu recipe on fibrotic liver in rats. Evid. Based. Complement. Alternat. Med. 2013, 972863. Xie, H.P., Liu, Z.P., Zhang, J.S., Dai, M., Xiao, G.M., Wu, W.K., Yang, H.Z., 2018. Traditional Chinese Medicine Syndrome Patterns and Their Association with Hepatitis B Surface Antigen Levels during the Natural History of Chronic Hepatitis B Virus Infection. Evid. Based. Complement. Alternat. Med. 2018, 7482593. Xu L, Xie T, Shen T, Jian S. 2019. Yinchenhao decoction for chronic hepatitis B: Protocol for 28

a systematic review and meta-analysis. Medicine (Baltimore). 98, e14648. Yang, N.H., Yuan, G.S., Zhou, Y.C., Liu, J.W., Huang, H.P., Hu, C.G., Xiong, L., Li, Y., Zhou, F.Y., Yang, S.L., Zhou, Y.P., 2016. Entecavir combined with Fufang Biejia Ruangan tablet in treatment of chronic hepatitis B patients with liver fibrosis: 96-week efficacy analyses. Nan. Fang. Yi. Ke. Da. Xue. Xue. Bao. 36, 775-779. Yang, F.R., Fang, B.W., Lou, J.S., 2013. Effects of Fufang Biejia Ruangan pills on hepatic fibrosis in vivo and in vitro. World. J. Gastroenterol. 19, 5326-5333. Yin, S.S., Wang, B.E., Wang, T.L., Jia, J.D., Qian, L.X.. 2004. The effect of Cpd 861 on chronic hepatitis B related fibrosis and early cirrhosis: a randomized, double blind, placebo controlled clinical trial. Zhonghua. Gan. Zang. Bing. Za. Zhi. 12, 467-470. Yoon, Y.J., Friedman, S.L., Lee, Y.A., 2016. Antifibrotic Therapies: Where Are We Now? Semin. Liver. Dis. 36, 87-98. You, H., Wang, B., Wang, T., 2000. Proliferation and apoptosis of hepatic stellate cells and effects of compound 861 on liver fibrosis. Zhonghua. Gan. Zang. Bing. Za. Zhi. 8, 78-80. You, H., Wang, B., Ma, X., 2001. Herbal compound 861 inhibits NF-kappa B binding activity of hepatic stellate cells in vitro. Zhonghua. Gan. Zang. Bing. Za. Zhi. 9, 73-74. Zhang, L., Schuppan, D., 2014. Traditional Chinese Medicine (TCM) for fibrotic liver disease: hope and hype. J. Hepatol. 61, 166-168. Zhang, H., Wang, X., Hu, P., Zhou, W., Zhang, M., Liu, J., Wang, Y., Liu, P., Luo, G., 2016. Serum Metabolomic Characterization of Liver Fibrosis in Rats and Anti-Fibrotic Effects of Yin-Chen-Hao-Tang. Molecules. 21, E126. Zhang, L.J., Sun, M.Y., Ning, B.B., Zhang, W.M., Chen, G.F., Mu, Y.P., Zhang, H., Liu, J., Bian, Y.Q., Liu, P., 2014. Xiayuxue Decoction attenuates hepatic stellate cell activation and sinusoidal endothelium defenestration in CCl4-induced fibrotic liver of mice. Chin J Integr Med. 20, 516-523. Zhang, G.B., Song, Y.N., Chen, Q.L., Dong, S., Lu, Y.Y., Su, M.Y., Liu, P., Su, S.B., 2015. Actions of Huangqi decoction against rat liver fibrosis: a gene expression profiling analysis. Chin. Med. 10, 39. Zhang, X., Xu, Y., Chen, J.M., Liu, C., Du, G.L., Zhang, H., Chen, G.F., Jiang, S.L., Liu, C.H., Mu, Y.P., Liu, P., 2017. Huang Qi Decoction Prevents BDL-Induced Liver Fibrosis Through Inhibition of Notch Signaling Activation. Am. J. Chin. Med. 45, 85-104. Zhang, B., Hu, M., Huang, L., Pu, Y., Pei, H., Hua, Z., Yao, S., 2014. Effect of Fuzheng Huayu capsule combined with Pegasys on genotype 1 hepatitis C fibrosis and cell apoptosis. Exp. Ther. Med. 8, 1123-1126. Zhang, F., Wang, B., Wang, T., Jia, J., Dong, Z., Zhang, J., 2000. Three-dimensional reconstruction of experimental fibrotic liver tissue and effect of herbal compound on it. Zhonghua. Gan. Zang. Bing. Za. Zhi. 8, 355-357. Zhang, L., Chang, Y., 2012. Experimental study on effect of dahuang zhechong wan combined 29

with adefovir dipivoxil in preventing hepatic fibrosis in patients with chronic hepatitis B. Zhongguo. Zhong. Yao. Za. Zhi. 37, 862-864. Zheng, T.H., Liu, W., Li, S.P., Yang, T., Wang, C.H., Liu, C.H., 2015. Effect of Fuzheng Huayu recipe on CYP450 isozymes in normal and liver fibrosis rats. Zhongguo. Zhong. Yao. Za. Zhi. 40, 1166-1172. Zhou, Y.N., Mu, Y.P., Fu, W.W., Ning, B.B., Du, G.L., Chen, J.M., Sun, M.Y., Zhang, H., Hu, Y.Y., Liu, C.H., Xu, L.M., Liu, P., 2015. Yiguanjian decoction and its ingredients inhibit angiogenesis in carbon tetrachloride-induced cirrhosis mice. BMC. Complement. Altern. Med. 15, 342. Zhu, Y., Yin, C., Ma, X., Ma, H., Jia, J., Wang, B., 2002. The effect of herbal compound 861 on mRNA levels of MMP-2 and its activities in experimental rats liver fibrosis. Zhonghua. Shi. Yan. He. Lin. Chuang. Bing. Du. Xue. Za. Zhi. 16, 348-350.

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