Optimized project of traditional Chinese medicine in treating chronic kidney disease stage 3: A multicenter double-blinded randomized controlled trial

Journal of Ethnopharmacology 139 (2012) 757–764

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Optimized project of traditional Chinese medicine in treating chronic kidney disease stage 3: A multicenter double-blinded randomized controlled trial Yong-jun Wang a,∗ , Li-qun He b , Wei Sun c , Ying Lu a , Xiao-qin Wang d , Pei-qing Zhang e , Lian-bo Wei f , Shi-li Cao g , Ni-zhi Yang h , Hong-zhen Ma i , Jing Gao j , Ping Li k , Xiao-juan Tao l , Fa-Huan Yuan m , Jing Li j , Chen Yao n , Xusheng Liu h a

Department of Nephrology, Hangzhou Hospital of Traditional Chinese Medicine Affiliated to Zhejiang University of Chinese Medicine, Hangzhou, Zhejiang Province 310007, China Department of Nephrology, Shuguang Hospital, Shanghai University of Chinese Medicine, Shanghai, China c Department of Nephrology, Affiliated Hospital, Jiangshu University of Chinese Medicine, Nanjing, China d Department of Nephrology, Hubei Hospital of Traditional Chinese Medicine, Hubei Province, China e Department of Nephrology, Heilongjiang Academy of traditional Chinese Medicine, Heilongjiang Province, China f Department of Nephrology, Southern Medical University Affiliated Zhujiang Hospital, Guangzhou, China g Department of Nephrology, The First Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China h Department of Nephrology, Guangdong Hospital of Traditional Chinese Medicine, Guangdong Province, China i Department of Nephrology, Zhejiang Hospital of Traditional Chinese Medicine, Zhejiang Province, China j Department of Nephrology, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China k Department of Pharmacology, Institute of Clinical Medical Science, China-Japan Friendship Hospital, Beijing, China l Department of Nephrology, Hangzhou Red-Cross Hospital, Zhejiang Province, China m Department of Nephrology, Xinqiao Hospital Affiliated to the Third Military Medical University, Chongqing, China n Department of Statistics, The First Affiliated Hospital, Peking University, Beijing, China b

a r t i c l e

i n f o

Article history: Received 15 September 2011 Received in revised form 24 November 2011 Accepted 2 December 2011 Available online 13 December 2011 Keywords: Chronic kidney disease Traditional Chinese medicine Fangjihuangqi decoction Dangguibuxue decoction Xiayuxue decoction Tufuling decoction Chronic renal failure

a b s t r a c t Ethnopharmacological relevance: Stage 3 is the key phase of chronic kidney disease. Traditional Chinese medicine (TCM) has been used for the treatment of chronic kidney disease. But a large sample trial is desirable. Materials and methods: A total of 578 Chinese patients with primary glomerulonephritis in CKD stage 3 were randomly assigned to three groups: patients received TCM (TCM group), benazepril (Ben group), TCM combined with benazepril (TCM + Ben group). Patients were followed up for 24 weeks. The primary endpoint was the time to the composite of 50% increased of serum creatinine, end stage renal disease or death. Results: eGFR in the TCM and the TCM + Ben group were improved (week 24 vs. baseline, P < 0.05) while eGFR in the Ben group was decreased (week 24 vs. baseline, P > 0.05). 24 h urinary protein excretion (UP) and urinary albumin/creatinine (UAlb/Cr) were decreased in the TCM + Ben (week 24 vs. baseline, P < 0.05) and the Ben group (week 24 vs. baseline, P > 0.05). UP and UAlb/Cr were increased in the TCM group to week 12, then were stable (week 24 vs. baseline, P < 0.05). The hemoglobin in the TCM group was also improved (week 24 vs. baseline, P < 0.05). The accumulative survival rate in the TCM + Ben group was higher than that in the TCM group and the Ben group (P = 0.044). Side effects in the TCM group were the lowest in these groups (P < 0.05). The patients with dry cough in the TCM + Ben group and the Ben group were increased as compared with the TCM group (P < 0.05). Hyperkalemia happened less frequently in the TCM group as compared with the other two groups (P = 0.052). Conclusions: For the patients with CKD stage 3, TCM can improve eGFR and hemoglobin with lower side effects. Benazepril significantly decreased the proteinuria. Chinese medicine integrated with benazepril can ameliorate renal function and decrease proteinuria synergistically. © 2011 Elsevier Ireland Ltd. All rights reserved.

1. Introduction Abbreviations: TCM, traditional Chinese medicine; CKD, chronic kidney disease; GFR, glomerular filtration rate; UP, urinary protein excretion; ACEI, angiotensin converting enzyme inhibitor; CGN, chronic glomerulonephritis; Hb, hemoglobin; BP, blood pressure; RCT, randomized controlled trial; UAlb/Cr, urinary albumin/creatinine. ∗ Corresponding author. Tel.: +86 0571 85827685; fax: +86 0571 85827685. E-mail address: [email protected] (Y.-j. Wang). 0378-8741/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.jep.2011.12.009

The prevalence of chronic kidney disease (CKD) increased gradually is accounted for about 7–11.5% in general population worldwide (Chen et al., 2009; White et al., 2010). The annual incidence rate of ESRD was increased from 39.4/million in 1988 to 98.3/million in 2002 with augmentation rate of 4.1% in USA.

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The point prevalence of ESRD, with the primary cause being primary chronic glomerulonephritis (CGN), is 33.16/million in China in 1999 (Dialysis and Transplantation Registration Group, 2002), and increased to 79.1/million in 2008 (Chinese Society of Blood Purification, 2010). Patients with baseline CKD exhibited 65% higher total costs 10 years after baseline examination than those without (Baumeister et al., 2009). It is important to inhibit the progress of renal function before CKD stage 3, after that stage renal function aggravates progressively with increased cardiovascular events (Futrakul and Futrakul, 2009; Zhang et al., 2007). Angiotensin converting enzyme inhibitor (ACEI) has been demonstrated to reduce proteinuria and protect renal function from deterioration in CKD patients even in advanced stage. However, ACEI agents also have some side effects such as dry cough and rise of serum creatinine and potassium. Traditional Chinese medicine (TCM), used for treating CGN since ancient time in China, has been demonstrated to reduce proteinuria, inhibit renal fibrosis and improve renal function (Dou et al., 2009; Peng et al., 2005; Pu et al., 2009; Ren et al., 2009; Wu et al., 2008b; Zuo et al., 2009). However, most of the previous clinical studies focused on effects of TCM in CKD patients were retrospective. A few recent prospective randomized controlled trials (RCT), indicating that a mount of Chinese patent tablets can reduce proteinuria and inhibit renal function aggravation comparable to ACEI in IgA nephropathy patients, were designed without following differentiation of symptoms and signs (Wang et al., 2001), the rule of TCM associated with the therapeutic effects. An optimized TCM scheme in treating CKD determined by the three major national TCM renal centers in China was designed for the treatment of chronic kidney disease. The TCM syndrome patterns (Wang et al., 2001) of CKD patients were classified into Qi yin deficiency, blood stasis in kidney, wind-dampness interfering in the kidney and endoretention of damp heat (Zhen et al., 2010). Here, we investigated for the first time the effects and the safety of this optimized project of traditional Chinese medicine by differentiation of symptoms and signs in treating chronic glomerulonephritis in CKD stage 3. 2. Methods 2.1. Study design This was a prospective, multicenter, double blinded and randomized controlled study. We conducted the study in accordance with the ethical principles of the Declaration of Helsinki, the Good Clinical Practice guidelines of the international Conference on Harmonization, and local regulatory requirements. The study protocol was approved by the ethics committee at each participating center. A study period of 6 months was chosen based on the previous clinical pilot trials. 2.2. Patients Patients were recruited at 13 hospitals in China (Supplementary Table 1). Between January 2006 and December 2009, consecutive patients aged from 18 to 65 years old were screening for this study. Eligible patients met the following inclusion criteria. (1) The patients signed written informed consent. (2) Primary chronic nephritis with eGFR from 30 to 59 ml/min (CKD stage 3). (1) 24 h proteinuria less than 2 g/d. (2) Not received ACEI or ARB for at least 2 weeks. (3) Blood pressure (BP) less than 140/90 mmHg. Exclusion criteria were: (1) women in pregnancy or lactation. (2) Patients with severe disease in other organs or cancer, active tuberculosis, positive HBeAg, renal transplantation. (3) Current treatment with corticosteroid, immunosuppressive agents. (4) With psychotic

diseases. (5) Enrolled in other trials. (6) Hemoglobin (Hb) less than 80 g/L. (3) Shed criteria. (These patients cannot go on receiving the therapy of the research, but they will be followed up to the end of the trial.) (1) Severe side events. (2) Severe complications. (3) Violate the trial regimen. (4) Significantly increased proteinuria. (5) Lose to follow up. (6) Pregnancy. (4) Rejection criteria. (The patients have undergone randomization but will be excluded) (1) Refuse to take the medicine of this trial. (2) Without any follow up data. 2.3. Treatment Eligible patients obtained their sequence numbers from the coordinator and were randomly allocated into three groups according to a computer-generated randomization sequence list: patients received traditional Chinese medicine plus placebo of benazepril (TCM group), 10 mg/d benazepril plus placebo of TCM (Ben group), traditional Chinese medicine combined with 10 mg/d benazepril (TCM + Ben group). All these patients received general therapy for chronic renal failure as follows: (1) protein intake (50% was high quality protein) was 0.6 g/(kg d) with sufficient calorie supply (30–35 kcal/kg). (2) Antihypertensive agents except ACEI or ARB was given to the patients with BP > 140/90 mmHg. The patient will not be enrolled in this study until his/her BP was less than 140/90 mmHg. (3) Patients received antihyperlipidemic agents including fenofibrate and/or atorvastatin for hyperlipoidemia. (4) An optimized TCM scheme with four TCM syndrome patterns with related four ancient classic based decoctions for the treatment of CKD determined by the three major national TCM renal centers (Hangzhou Hospital of TCM, Shanghai Shuguang Hospital and Jiangshu hospital of TCM) were used in this study (Zhen et al., 2010). Four TCM decoctions were processed into granules capsulated in a little tin foil bag in Jiangyin Tianjiang Pharmaceutial. Co. Ltd (China) (The qualitative, quantitative and preparation of the traditional Chinese herbs granules used in this study shown in the supplementary document provided.) were designed according to the four differentiations evaluated based on a TCM score sheet (Fig. 1 and supplementary Tables 2–5) (Song et al., 2007). (a) Replenishing qi and blood decoction for the treatment of Qi Yin/Xue deficiency patterns (Addition and subtraction based on the classic Dang Gui Bu Xue decoction): Astragalus membranaceus, Radix Pesudostellariae, Radix angelicae sinensis, Fructus ligustri lucidi. (b) Promoting blood flow decoction for the treatment of blood stasis in the kidney patterns (Addition and subtraction based on the classic Xia Yu Xue decoction): Radix salviae miltiorrhizae, Semen persicae, Herba centellae, Radix et rhizoma rhei. (c) Expel wind-evil and remove wetness decoction for the treatment of wind-dampness interfering in the kidney patterns (Addition and subtraction based on the classic Fang Ji Huang Qi decoction): Tripterygium wilfordii Hook. F, Radix Stephaniae Tetrandrae, Winged Euonymus Twig. (d) Clearing heat and dissipating dampness decoction for the treatment of patterns of endoretention of damp heat (Addition and subtraction based on the classic Tu Fu Ling decoction): Rhizoma polygoni cuspidati, Rhizoma coptidis, Rhizoma smilacis glabrae, Serissa serissoides (DC.) Druce. Benazepril placebo was made of lactose, starch, carboxymethyl starch sodium and magnesium Stearate capsulated in a capsule that was comparable to the Benazepril capsule. TCM placebo granules separated to four TCM patterns were made of lactose, starch, edible colorant and bitter taste agents capsulated in a little tin foil bag that was the same as the four kinds of TCM granules. These TCM granules were taken one bag twice per day. 10 mg benazepril was taken once orally per day. 2.4. Measurement These patients were observed for 24 weeks. eGFR (MDRD formula) (Levey et al., 1999), 24 h proteinuria, urinary

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Fig. 1. TCM evaluation in every time points in the patients who have been randomized into one of the 3 groups.

albumin/creatine, TCM score (the score obtained using four TCM assessing sheets, supplementary Tables 2–5), serum uric acid, blood routine, urine routine, stool routine, electrocardiogram, and hepatic function were measured. The primary efficacy variable was time to the first event for the composite end point: 50% of increased serum creatinine, end stage renal disease and death. 2.5. Statistical method The data were analyzed by the department of statistics in the first affiliated hospital of Peking University, and were express as mean ± SD when they were normal distributive or median when were abnormal distribution. We estimated the sample size using nQuery Advisor Software. Our pilot study and previous references showed that the remission rate of ACEI was about 30%, and the remission rate of ACEI combined with TCM was 45%. Thus, the

enrollment of 186 patients per group would provide the study with a statistical power of 85% percent at a two sided significance level of 0.05. The primary and secondary end points were analyzed according to the intention-to-treat principle. Enumeration data were analyzed using Chi square test. Measurement data with normal distribution were analyzed using ANOVA test. Otherwise, the data will be analyzed with rank-sum test. Kaplan–Meier method was adopted for survival analysis. A P-value less than 0.05 was considered significant different.

3. Results 578 Chinese patients were identified for this study and randomly assigned to the three groups from January 2006 to July 2008 (Fig. 2). The baseline characteristics of these patients were similar

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Fig. 2. Patients’ enrollment and randomization.

Table 1 Baseline characteristics of the patients with chronic kidney disease.

Age (yr) Female sex-no. (%) Weight (kg) Height (cm) SBP (mmHg) DBP (mmHg) eGFR (ml/min) UP (mg) UAlb/Cr (g/mg) TCM score TCM patterns n (%)# Qi Yin/Xue Blood stasis Wind-dampness Damp heat

Ben group (n = 189)

TCM group (n = 192)

TCM + BEN group (n = 191)

P-Value*

49.04 ± 10.47 52.38 62.45 ± 11.03 164.02 ± 7.27 124.26 ± 10.48 78.89 ± 6.70 44.50 ± 9.02 690.00 (280.50, 1225.00) 0.31 (0.09, 0.72) 38.04 ± 14.88

47.33 ± 10.93 45.31 63.92 ± 12.29 164.70 ± 7.77 124.78 ± 11.03 80.04 ± 7.04 45.26 ± 10.12 722.00 (300.00, 1450.00) 0.30 (0.10, 0.88) 38.65 ± 13.91

49.32 ± 11.37 52.88 62.62 ± 10.78 163.31 ± 7.50 125.03 ± 10.49 78.71 ± 7.27 44.68 ± 9.82 590.00 (250.00, 1128.00) 0.30 (0.07, 0.66) 36.90 ± 13.04

0.16 0.25 0.39 0.20 0.77 0.13 0.72 0.29 0.56 0.46

184 (97.4) 127 (67.2) 138 (73.0) 67 (35.4)

183 (95.3) 144 (75.0) 133 (69.3) 72 (37.5)

184 (96.3) 140 (73.3) 127 (66.5) 75 (39.3)

0.57 0.21 0.38 0.74

SBP: systolic blood pressure; DBP: diastolic blood pressure; UP: 24 h proteinuria; UAlb/Cr: urinary albumin/creatinine; Qin Yin/Xue: Qi Yin/Xue deficiency patterns; Blood stasis: Blood stasis in the kidney patterns; Wind-dampness: wind-dampness interfering in the kidney patterns1; Damp heat: endoretention of damp heat patterns * P-Values were calculated with the use of ANOVA for continuous variables and with the use of the chi-square test for categorical variables. # Patient may have 1 to 4 of these four TCM patterns.  The available cases in each indexes may have a little deviation. (eg. For the evaluation of eGFR in the baseline there are 188 cases in the Ben group, 191 in the TCM group and 191 in the TCM+BEN group, as same as the cases enrolled in the therapeutic effects evaluation).

Table 2 The diagnosis of the enrolled patients undergoing renal biopsy.

Diagnosis

IgAN

FSGS

MsPGN

PSG

SG

FG

MCD

MN

MPGN

Unclear

Total

72

11

17

2

8

5

3

1

1

4

124

FSGS: focal segmental glomerular sclerosis; MsPGN: mesangial proliferative nephritis; PSG: proliferative sclerosis glomerulonephritis; SG: sclerosis glomerulonephritis; FG: focal glomerulonephritis; MCD: minimal change disease; MN: membranous nephropathy; MPGN: membranoproliferative glomerulonephritis

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among these three groups (572cases, Table 1). The renal pathological diagnose of 124 patients undergoing renal biopsy was shown in Table 2. Then 569 cases were included in the therapeutic effects analysis. 3.1. eGFR eGFR in the Ben group, TCM group and TCM + Ben group were 44.50 ± 9.02 ml/min, 45.26 ± 10.12 ml/min and 44.68 ± 9.82 ml/min, respectively, at baseline (the same cases as in the table1) (P > 0.05). At week 24, eGFR in the Ben group was gradually decreased to 43.00 ± 12.37 ml/min (vs. baseline, P > 0.05); eGFR was increased to 48.46 ± 15.90 ml/min in the TCM group (vs. baseline, P < 0.05) and 48.31 ± 17.50 ml/min in the TCM + Ben group (vs. baseline, P < 0.05). By an analysis of covariance corrected with eGFR at baseline, the eGFR at week 24 in the TCM group and TCM + Ben group were significantly higher than that in the Ben group (P < 0.05). eGFR at week 24 in the TCM + Ben group was also increased as compared with the TCM group (P > 0.05) (Fig. 3A). 3.2. 24 h proteinuria (UP) There was no significant difference in the UP between these three groups at baseline (TCM group: 725.98 mg/24 h, TCM + Ben group: 590.00 mg/24 h, Ben group 695.00 mg/24 h) (P > 0.05). At week 24, UP in the TCM group was 990.00 mg/24 h (vs. baseline, P < 0.05), 510 mg/24 h (vs. baseline, P > 0.05) in the Ben group and 453.50 mg/24 h in the TCM + Ben group, respectively (vs. baseline, P < 0.05). The reduction rate of UP ((UPbaseline − UPweek 24 )/UPbaseline × 100%) in the Ben group (reduction median: 0%) and TCM + Ben group (reduction median: 8.83%) was decreased significantly as compared with the TCM group (reduction median: −24.80%) (P < 0.05). Reduction rate in the TCM + Ben group was also lower than that in the Ben group (P > 0.05) (Fig. 3B). 3.3. Urinary albumin/creatinine (UAlb/Cr) UAlb/Cr at baseline between these three groups was also comparable (Ben group: 0.31 mg/gcr, TCM group: 0.30 mg/gcr and TCM + Ben group: 0.30 mg/gcr) (P > 0.05). At week 24, UAlb/Cr was 0.26 mg/gcr in the Ben group (vs. baseline, P > 0.05), 0.48 mg/gcr in the TCM group and 0.22 mg/gcr (vs. baseline, P > 0.05) in the TCM + Ben group (vs. baseline, P < 0.05). The reduction rate of Alb/Cr ((UAlb/Crbaseline − UAlb/Crweek 24 )/UAlb/Crbaseline × 100%) in the Ben group (reduction median: 1%) and TCM + Ben group (reduction median: 1%) was decreased significantly as compared with the TCM group (reduction median: −1%) (P < 0.05) (Fig. 3C).

Fig. 3. (A) eGFR (Mean ± SD) during follow up. In the end of observation, eGFR in the TCM and the TCM + Ben group were higher than the Ben group (P < 0.05). (B) 24 h proteinuria (Median) during follow up. In the end of observation, 24 h proteinuria in TCM group was increased at week 12, and remained stable at week 24. 24 h proteinuria in TCM + Ben and Ben group was decreased as compared with TCM group (P < 0.05). 24 h proteinuria in TCM + Ben group was also lower than Ben group (P > 0.05). (C) UAlb/Cr (Median) during follow up. In the end of observation, UAlb/Cr in TCM group was increased from week 4 to week 12, and remained to the end. UAlb/Cr in TCM + Ben and Ben group was decreased as compared with TCM group (P < 0.05). UAlb/Cr in TCM + Ben group was also lower than Ben group (P > 0.05). (D) Hemoglobin (Mean ± SD) during follow up. In the end of observation, Hb in TCM group was increased as compared with baseline. Hb in TCM group was higher than Ben and TCM + Ben group (P < 0.05). (E) TCM score (Mean ± SD) during follow-up. The TCM score in each group were all decreased at week 24 as compared with baseline. TCM score in TCM + Ben group was decreased significantly as compared with the other two groups (P < 0.05).

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Y.-j. Wang et al. / Journal of Ethnopharmacology 139 (2012) 757–764 Table 3 Adverse events in each group. Adverse event

Ben group (n = 189)

Liver injury Hyperkalemia Dry cough Hypotension Anemia Upper respiratory tract infection Gastrointestinal symptoms

9 10 5 1 8 5 1

1

3

Total

39

25

46

TCM group (n = 192) 2 7 0 0 7 8

TCM + Ben group (n = 191)

P-Value

5 18 6 0 6 8

0.087 0.052 0.01 0.33 0.85 0.66 0.48 0.019

4. Discussion

Fig. 4. Kaplan–Meier estimates of the percentage of patients not reaching the primary composite end point of a 50% increase of the serum creatinine, end-stage renal disease, or death.

3.4. Hemoglobin (Hb) At the baseline, Hb was 127.77 ± 19.37 g/L in the Ben group, 127.31 ± 18.47 g/L in the TCM group and 126.26 ± 18.92 g/L in the TCM + Ben, respectively (P > 0.05). At week 24, Hb was 128.84 ± 17.84 in the Ben group (vs. baseline, P > 0.05), 129.57 ± 21.82 in the TCM group (vs. baseline, P < 0.05) and 124.60 ± 18.85 (vs. baseline, P > 0.05) in the TCM + Ben group. By an analysis of covariance corrected with Hb at baseline, Hb in the TCM group was increased significantly as compared with the Ben group and TCM + Ben group (P < 0.05) (Fig. 3D). 3.5. TCM score The TCM score was 38.13 ± 14.87 in the Ben group, 38.71 ± 13.92 in the TCM group and 36.80 ± 13.00 in the TCM + Ben group (P > 0.05). At week 24, TCM score was 22.82 ± 11.72 in the Ben group, 23.28 ± 12.09 in the TCM group, 19.54 ± 11.32 in the TCM + Ben group. The TCM score in the TCM + Ben group was significantly lower than that in the Ben group by an analysis of covariance corrected with the data at baseline (P < 0.05). The TCM score in the TCM group was lower than that in the Ben group (P > 0.05) (Fig. 3E). 3.6. Survival analysis Eleven patients in the Ben group reached the primary end point compared with 5 patients in the TCM groups and 4 patients in the TCM + Ben groups (P = 0.044) (Fig. 4), indicating that the patients reached the primary end points in the TCM + Ben group was significantly lower as compared with the Ben group. 3.7. Safety No patients died during the whole research period. Dry cough occurred in 5 patients in Ben group versus 6 patients in TCM + Ben group and no one in the TCM group (P < 0.05). Hyperkalemia occurred in 18 patients in TCM + Ben group compared with 10 patients in Ben group and 7 patients in TCM group (P > 0.05). There is no significant difference of other side effects among these groups in the other adverse effects. As a whole, side effects events were lowest in the TCM group as compared with the other two groups (P < 0.05) (Table 3).

In the present large sample randomized controlled trial, we demonstrated for the first time that it was feasible to assess the effects of TCM following the differentiation of symptoms and signs using the RCT method. This study also indicates that the four types of TCM symptoms in this study are suitable for the determination of TCM treatment based in pathogenesis obtained through differentiation of symptoms and signs of CKD stage 3 patients. Most of these patients with 2 or more types of TCM symptoms were given multiple types of decoction granules by the evaluation using the TCM assessment tables. We also demonstrated that the TCM decoction granules improved the glomerular filtration rate. The glomerular filtration rate also was increased in the patients treated with TCM combined with benazepril that was even higher than that in the patients treated with TCM. TCM did not decrease proteinuria significantly. But TCM integrated with benazepril significantly decreased proteinuria that was even lower than that in the Ben group. TCM also can improve anemia in the patients with CKD stage 3. TCM has been used for the treatment of renal disease for thousands of years in China. The clinical evidences obtained from the large sample clinical trial was insufficient due to the disparity of the individualization of TCM therapy and the unity of the RCT method. Previous trials have demonstrated some effects of TCM by RCT researches that adopted a fixed decoction in the whole research period (Cao et al., 2010; Gim et al., 2009). However, this method based on the diagnosis of western medicine cannot fit the various patterns of syndrome of TCM in the different patients. It also was not appropriate for the patients with multi-pattern of syndrome or the patients with pattern change of TCM, which will certainly affect the therapeutic effects of TCM. Here we adopted four separated types of decoction granules according to the four TCM patterns of syndromes covering the patients with CKD stage 3. Patients with more than one TCM pattern of syndromes received combination of more than one type of decoction granules. And the types of decoction granules can be altered following the change of TCM pattern. This is the first randomized controlled trial that fit not only the individualization of TCM but also the principles of clinical trials such as randomize, control, and double blind to provide the evidences of TCM therapeutic effects for the CKD stage 3. This randomized controlled trial also for the first time indicated that TCM improved renal function. At week 24, eGFR in TCM + Ben and TCM group was increased as compared with baseline (P < 0.05). Haemodynamic effects of benazepril to reduce glomerular blood flow can decrease 5–10% of eGFR after taken for 6 months (Hou et al., 2006, 2007; Shoda et al., 2006). Our study indicated that eGFR in TCM group was increased 2.66% as compared with decreased 3.53% in Ben group (P < 0.05). The accumulated survival rate in the TCM + BEN group was significantly improved as compared with the other two groups, indicating the decoction granules used in this study have renal protective effects. Previous reports have indicated

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that Astragalus mongholicus and salvia miltiorrhiza protect renal function in rats with acute or chronic renal failure (Huang et al., 2007; Ngai et al., 2005). Rhubarb and its derived components inhibit renal fibrosis and inflammation to repress the deterioration of renal function (Chan et al., 2003; Hu et al., 2009; Peng et al., 2005; Wang et al., 2007, 2009; Zhu et al., 2011). Radix salviae miltiorrhizae and its derived compounds alkanic acid have renal protective effects in ischemic kidney (Shen, 1988) or ischemia/reperfusion-induced renal injury (Kang et al., 2004). It suppresses mesangial proliferation and production of plasminogen activator inhibitor-1 induced by Angiotensin-II (Yuan et al., 2007, 2008). Radix salviae miltiorrhizae also have inhibitory effects on renal fibrosis and oxidative stress (Liu et al., 2006; Yokozawa and Chen, 2000; Yue et al., 2006). Berberine, the major component isolated from Rhizoma coptidis, suppresses experimental autoimmune tubulointerstitial nephritis in BALB/c mice (Marinova et al., 2000). Tetrandrine derived from Radix stephaniae tetrandrae have anti-inflammatory and immunomodulatory effects (Feng et al., 2008; Kang et al., 1996; Lai, 2002; Xue et al., 2008). Triptolide, the major component isolated from Tripterygium wilfordii Hook. F, also has inhibitory effects on inflammation and fibrosis in renal disease (Ding et al., 2011; Peng et al., 2005; Zhu et al., 2010). Oleanolic acid and ursolic acid derived from Fructus ligustri lucidi have anti-oxidative stress effects (Yin and Chan, 2007). These effects of herbs may be the explanation of the improvement of renal function in the patients in the TCM and TCM + BEN group. Previous RCTs indicated that some Chinese patent tablets can decrease 30–40% proteinuria that was compared to fosinopril (Chen et al., 2006a, 2007). Tripterygium wilfordii and its derived component triptolide were the most effective agents in decreasing proteinuria by inhibiting inflammatory cell filtration and protecting podocytes (Chen et al., 2010; Zheng et al., 2008). Stephania tetrandra decreases proteinuria of nephropathy rats (Huang et al., 2007). Berberine suppresses proteinuria in original-type anti-GBM nephritis (Hattori et al., 1992). Astragalus mongholicus and angelica root regulate the immune response to reduce proteinuria (Gao et al., 2006). Tripterygium wilfordii Hook. F, in the TCM decoctions of our study, has been demonstrated to reduce proteinuria in the previous studies. However, in the present trial, the proteinuria in the TCM group was not decreased significantly. Subsequently, triptolide, the important ingredient of Tripterygium wilfordii Hook. F, was not detected in TCM granuels used in this study, which may be associatd with the quality of the herbs and the processing methods of the TCM granules, it is worth attention. In the other hand, the increase of proteinuria in the TCM group was alleviated after week 12, indicating that the accumulated effects of TCM on the proteinuria may be identified by a longer observation. It is noticeable that eGFR in TCM + BEN group was increased as compared with TCM (P > 0.05) and Ben group (P < 0.05), whereas proteinuria in TCM + BEN group was decreased as compared with TCM (P < 0.05) and BEN group (P > 0.05). Previous reports indicated that benazepril inhibits RAAS system, TGF-␤ and PDGF signaling pathway to repress inflammation and renal fibrosis (Aldigier et al., 1998). TCM components in this study can inhibit inflammation and fibrosis by affects Smad2 (Zhu et al., 2010), NF-␬B, p38, immuno-system and oxidative stress (Chen et al., 2006b; Feng et al., 2008; Gui et al., 2007; Heo et al., 2010; Peng et al., 2005; Tan et al., 2006; Wang et al., 2006) besides TGF-␤ signaling (Kim et al., 2009; Zuo et al., 2009). These different mechanisms may contribute to the synergic improvement effects on the renal function and proteinuria of TCM decoction granules integrated with benazepril. The Chinese decoctions used in this study also improved hemoglobin. Previous reports demonstrated that Astragalus mongholicus and angelica root improve anemia (Wu et al., 2008a; Zhang and Wu, 2008). ACEI blocks RAAS system to reduce erythropoietin (Donnelly and Shah, 1999; Inoue et al., 2008), which

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may explain the insignificant hemoglobin improvement in the TCM + BEN group and the Ben group. Dry cough ocurred more frequently in the Ben group and TCM + Ben group as compared with the TCM group due to the accumulation of bradykinin and tachykinin caused by the inhibition of angiotesin conversion enzyme. Increased serum potassium, happening more frequently in TCM + BEN group due to ACEI agents and potassium in the decoctions and decreased excretion of potassium in CKD stage 3 patients without significantly differences as compared with the TCM group. But the total adverse effects in the TCM was the lowest as compared with the other two groups. In summary, this first RCT study about the effects of Chinese decoctions on CKD stage 3 patients with chronic glomerulonephritis following the differentiation of symptoms and signs demonstrated that Chinese decoctions can protect renal function, improve anemia. Chinese decoctions combined with benazepril can synerigisticly decrease proteinuria and increase GFR as compared with either TCM decoctions to improve GFR or benazepril to reduce proteinuria, respectively.

Acknowledgements This study was supported by grants from projects in the Chinese National Science and Technology Pillar Program during the 11th 5-year plan period (no. 2006BAI04A07). Parts of this work were selected for oral presentations at the meetings of American Society of Nephrology, November 8 through 13, 2011 in Philadelphia, PA, USA. This randomized controlled trial was registered at the Chinese Clinical Trial Registry (RCT registration code: ChiCTR-TRC-00000204). We are appreciated for some statistic analyses and manuscript processing of Dr. Bin Zhu in the department of nephrology in Hangzhou Hospital of Traditional Chinese Medicine.

Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.jep.2011.12.009.

References Aldigier, J.C., Meur, Y.L., Brunel, P., 1998. Protection of renal function with ACE inhibitors. Experience with benazepril. Clinical Drug Investigation 16, 463–472. Baumeister, S.E., Boger, C.A., Kramer, B.K., Doring, A., Eheberg, D., Fischer, B., John, J., Koenig, W., Meisinger, C., 2009. Effect of chronic kidney disease and comorbid conditions on health care costs: a 10-year observational study in a general population. American Journal of Nephrology 31, 222–229. Cao, H., Ren, M., Guo, L., Shang, H., Zhang, J., Song, Y., Wang, H., Wang, B., Li, X., Hu, J., Wang, X., Wang, D., Chen, J., Li, S., Chen, L., 2010. JinQi-Jiangtang tablet, a Chinese patent medicine, for pre-diabetes: a randomized controlled trial. Trials 11, 27. Chan, T.M., Leung, J.K., Tsang, R.C., Liu, Z.H., Li, L.S., Yung, S., 2003. Emodin ameliorates glucose-induced matrix synthesis in human peritoneal mesothelial cells. Kidney International 64, 519–533. Chen, N., Wang, W., Huang, Y., Shen, P., Pei, D., Yu, H., Shi, H., Zhang, Q., Xu, J., Lv, Y., Fan, Q., 2009. Community-based study on CKD subjects and the associated risk factors. Nephrology, Dialysis, Transplantation 24, 2117–2123. Chen, X.-M., Chen, J., Chen, Y.-P., Zhou, Z.-L., 2007. Multicentered, randomized, controlled clinical trial on patients with IgA nephropathy of Qi-yin deficiency syndrome type. Chinese Journal of Integrative Medicine 27, 101–105. Chen, X.-M., Chen, Y.-P., Zhou, Z.-L., Chen, J., Wei, R.-B., Dun, Y.-Y., 2006a. Prospective, multi-centered, randomized and controlled trial on effect of Shenle capsule in treating patients with IgA nephropathy of Fei-Pi Qi-deficiency syndrome. Chinese Journal of Integrative Medicine 26, 1061–1065. Chen, Y., Zhang, J., Li, J., Zhao, T., Zou, L., Tang, Y., Zhang, X., Wu, Y., 2006b. Triptolide inhibits B7-H1 expression on proinflammatory factor activated renal tubular epithelial cells by decreasing NF-kappaB transcription. Molecular Immunology 43, 1088–1098. Chen, Z.H., Qin, W.S., Zeng, C.H., Zheng, C.X., Hong, Y.M., Lu, Y.Z., Li, L.S., Liu, Z.H., 2010. Triptolide reduces proteinuria in experimental membranous nephropathy and protects against C5b-9-induced podocyte injury in vitro. Kidney International 77, 974–988.

764

Y.-j. Wang et al. / Journal of Ethnopharmacology 139 (2012) 757–764

Chinese Society of Blood Purification, 2010. Current burden of ESRD in China and it is estimated to be increasing faster in the near future. Chinese Journal of Blood Purification 9, 47–49. Dialysis and Transplantation Registration Group, C.S.o.N., Chinese Medical Association, 2002. The report about the registration of dialysis and transplantation in China 1999. Chinese Journal of Nephrology 17, 77. Ding, Z.X., Yang, S.F., Wu, Q.F., Lu, Y., Chen, Y.Y., Nie, X.L., Jie, H.Y., Qi, J.M., Wang, F.S., 2011. Therapeutic effect of total glucosides of paeony on lupus nephritis in MRL/lpr mice. Nan Fang Yi Ke Da Xue Xue Bao 31, 656–660. Donnelly, S., Shah, B.R., 1999. Erythropoietin deficiency in hyporeninemia. American Journal of Kidney Diseases 33, 947–953. Dou, C., Wan, Y., Sun, W., Zhagn, H., Chen, J., Shui, G., Yao, J., 2009. Mechanism of Chinese herbal medicine delaying progression of chronic kidney disease. Zhongguo Zhong Yao Za Zhi 34, 939–943. Feng, D., Mei, Y., Wang, Y., Zhang, B., Wang, C., Xu, L., 2008. Tetrandrine protects mice from concanavalin A-induced hepatitis through inhibiting NF-kappaB activation. Immunology Letters 121, 127–133. Futrakul, N., Futrakul, P., 2009. A mildly altered vascular homeostasis in early stage of CKD. Renal Failure 31, 538–543. Gao, Q.T., Cheung, J.K., Li, J., Chu, G.K., Duan, R., Cheung, A.W., Zhao, K.J., Dong, T.T., Tsim, K.W., 2006. A Chinese herbal decoction, Danggui Buxue Tang, prepared from Radix Astragali and Radix Angelicae Sinensis stimulates the immune responses. Planta Medica 72, 1227–1231. Gim, G.T., Kim, H.M., Kim, J., Whang, W.W., Cho, S.H., 2009. Antioxidant effect of tianwang buxin pills a traditional Chinese medicine formula: double-blind, randomized controlled trial. American Journal of Chinese Medicine 37, 227–239. Gui, M., Zhang, Y.F., Xiao, Z.Y., Sun, P., Dai, J.F., Wang, S.F., Rui, Y.C., Zhang, J.P., 2007. Inhibitory effect of emodin on tissue inhibitor of metalloproteinases-1 (TIMP1) expression in rat hepatic stellate cells. Digestive Diseases and Sciences 52, 200–207. Hattori, T., Furuta, K., Nagao, T., Nagamatsu, T., Ito, M., Suzuki, Y., 1992. Studies on the antinephritic effect of plant components (4): reduction of protein excretion by berberine and coptisine in rats with original-type anti-GBM nephritis. Japanese Journal of Pharmacology 59, 159–169. Heo, S.K., Yun, H.J., Noh, E.K., Park, S.D., 2010. Emodin and rhein inhibit LIGHT-induced monocytes migration by blocking of ROS production. Vascular Pharmacology 53, 28–37. Hou, F.F., Xie, D., Zhang, X., Chen, P.Y., Zhang, W.R., Liang, M., Guo, Z.J., Jiang, J.P., 2007. Renoprotection of optimal antiproteinuric doses (ROAD) study: a randomized controlled study of benazepril and losartan in chronic renal insufficiency. Journal of the American Society of Nephrology 18, 1889–1898. Hou, F.F., Zhang, X., Zhang, G.H., Xie, D., Chen, P.Y., Zhang, W.R., Jiang, J.P., Liang, M., Wang, G.B., Liu, Z.R., Geng, R.W., 2006. Efficacy and safety of benazepril for advanced chronic renal insufficiency. New England Journal of Medicine 354, 131–140. Hu, Q., Noor, M., Wong, Y.F., Hylands, P.J., Simmonds, M.S., Xu, Q., Jiang, D., Hendry, B.M., 2009. In vitro anti-fibrotic activities of herbal compounds and herbs. Nephrology, Dialysis, Transplantation 24, 3033–3041. Huang, L.M., Shi, X.Q., Liang, H., 2007. Effects of Radix Astragali and Fructus Corni on urinary protein pattern in nephropathy mice by microfluidic chip. Zhongguo Zhong Yao Za Zhi 32, 1324–1328. Inoue, A., Babazono, T., Iwamoto, Y., 2008. Effects of the Renin–Angiotensin system blockade on hemoglobin levels in type 2 diabetic patients with chronic kidney disease. American Journal of Hypertension 21, 317–322. Kang, D.G., Oh, H., Sohn, E.J., Hur, T.Y., Lee, K.C., Kim, K.J., Kim, T.Y., Lee, H.S., 2004. Lithospermic acid B isolated from Salvia miltiorrhiza ameliorates ischemia/reperfusion-induced renal injury in rats. Life Sciences 75, 1801–1816. Kang, H.S., Kim, Y.H., Lee, C.S., Lee, J.J., Choi, I., Pyun, K.H., 1996. Anti-inflammatory effects of Stephania tetrandra S. Moore on interleukin-6 production and experimental inflammatory disease models. Mediators of Inflammation 5, 280–291. Kim, S.K., Jung, K.H., Lee, B.C., 2009. Protective effect of Tanshinone IIA on the early stage of experimental diabetic nephropathy. Biological and Pharmaceutical Bulletin 32, 220–224. Lai, J.H., 2002. Immunomodulatory effects and mechanisms of plant alkaloid tetrandrine in autoimmune diseases. Acta Pharmacologica Sinica 23, 1093–1101. Levey, A.S., Bosch, J.P., Lewis, J.B., Greene, T., Rogers, N., Roth, D., 1999. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of diet in renal disease study group. Annals of Internal Medicine 130, 461–470. Liu, C.S., Cheng, Y., Hu, J.F., Zhang, W., Chen, N.H., Zhang, J.T., 2006. Comparison of antioxidant activities between salvianolic acid B and Ginkgo biloba extract (EGb 761). Acta Pharmacologica Sinica 27, 1137–1145. Marinova, E.K., Nikolova, D.B., Popova, D.N., Gallacher, G.B., Ivanovska, N.D., 2000. Suppression of experimental autoimmune tubulointerstitial nephritis in BALB/c mice by berberine. Immunopharmacology 48, 9–16. Ngai, H.H., Sit, W.H., Wan, J.M., 2005. The nephroprotective effects of the herbal medicine preparation, WH30+, on the chemical-induced acute and chronic renal failure in rats. American Journal of Chinese Medicine 33, 491–500. Peng, A., Gu, Y., Lin, S.Y., 2005. Herbal treatment for renal diseases. Annals of the Academy of Medicine, Singapore 34, 44–51. Pu, G.J., Wang, C., Zheng, P.D., He, L.Q., 2009. Effects of No.2 Renal Failure Recipe on expressions of cyclooxygenase-2 and -1 mRNAs in rats with chronic renal failure. Zhong Xi Yi Jie He Xue Bao 7, 1067–1072.

Ren, Y., Sun, W., Zhao, Y., Ma, Q., Wang, Z., 2009. Effect of Qufengtongluo recipe on expression of nephrin mRNA in adriamycin-induced nephropathy in rats. Zhong Nan Da Xue Xue Bao Yi Xue Ban 34, 1216–1223. Shen, Y.C., 1988. The protective effects of Salvia miltiorrhiza on the warm ischemic kidney: experimental study in animals. Zhonghua Wai Ke Za Zhi 26, 759–761, 783. Shoda, J., Kanno, Y., Suzuki, H., 2006. A five-year comparison of the renal protective effects of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in patients with non-diabetic nephropathy. Internal Medicine 45, 193–198. Song, D.-F., Li, X.-D., Xiang, N., 2007. The suggestions and researches on the determination of assessing sheet for the evaluation of traditional Chinese medicine syndrome patterns. Modern Journal of Integrated Traditional Chinese and Western Medicine 16, 1471. Tan, Y., Liang, Z., Shao, H., Du, F., 2006. Effect of water deficits on the activity of anti-oxidative enzymes and osmoregulation among three different genotypes of Radix Astragali at seeding stage. Colloids and Surfaces B: Biointerfaces 49, 60–65. Wang, C.H., Gao, Z.Q., Ye, B., Cai, J.T., Xie, C.G., Qian, K.D., Du, Q., 2007. Effect of emodin on pancreatic fibrosis in rats. World Journal of Gastroenterology 13, 378–382. Wang, J., Huang, H., Liu, P., Tang, F., Qin, J., Huang, W., Chen, F., Guo, F., Liu, W., Yang, B., 2006. Inhibition of phosphorylation of p38 MAPK involved in the protection of nephropathy by emodin in diabetic rats. European Journal of Pharmacology 553, 297–303. Wang, J., Zhao, Y., Xiao, X., Li, H., Zhao, H., Zhang, P., Jin, C., 2009. Assessment of the renal protection and hepatotoxicity of rhubarb extract in rats. Journal of Ethnopharmacology 124, 18–25. Wang, X.-H., Liu, Y.-C., Sun, G.-R., Li, Q.-Z., Li, Z.-Y., Li, D.-X., Zhang, X.-C., 2001. In: Wang, X.-H. (Ed.), The Basic Theories of Traditional Chinese Medicine. , 1st ed. People’s Medical Publishing House, Beijing, pp. 22–26. White, S.L., Polkinghorne, K.R., Atkins, R.C., Chadban, S.J., 2010. Comparison of the prevalence and mortality risk of CKD in Australia using the CKD epidemiology collaboration (CKD-EPI) and modification of diet in renal disease (MDRD) study GFR estimating equations: the AusDiab (Australian Diabetes, Obesity and Lifestyle) study. American Journal of Kidney Diseases 55, 660–670. Wu, X.L., Sun, W.S., Zhang, W.G., Qiao, C.L., Liu, R.X., 2008a. Clinical study of trilogy detoxicating therapy combined with routine Western medicine on patients with chronic renal failure. Chinese Journal of Integrative Medicine 14, 98–102. Wu, X.L., Sun, W.S., Zhang, W.G., Wang, Z., 2008b. Mechanism of the effect of Tongluo Recipe against glomerular sclerosis in rats. Nan Fang Yi Ke Da Xue Xue Bao 28, 1198–1201. Xue, Y., Wang, Y., Feng, D.C., Xiao, B.G., Xu, L.Y., 2008. Tetrandrine suppresses lipopolysaccharide-induced microglial activation by inhibiting NF-kappaB pathway. Acta Pharmacologica Sinica 29, 245–251. Yin, M.C., Chan, K.C., 2007. Nonenzymatic antioxidative and antiglycative effects of oleanolic acid and ursolic acid. Journal of Agricultural and Food Chemistry 55, 7177–7181. Yokozawa, T., Chen, C.P., 2000. Role of Salviae Miltiorrhizae Radix extract and its compounds in enhancing nitric oxide expression. Phytomedicine 7, 55–61. Yuan, J., Lu, Y.F., Chen, T.H., Zeng, X.F., 2007. Effects of Salvia miltiorrhiza on TGF-beta1, ROS and PAI-1 induced by angiotensin II in renal mesangial cells. Zhongguo Zhong Yao Za Zhi 32, 2400–2404. Yuan, J., Wang, X., Chen, T., Chen, G., Lu, Y., 2008. Salvia miltiorrhiza depresses plasminogen activator inhibitor-1 production through inhibition of angiotensin II. American Journal of Chinese Medicine 36, 1005–1015. Yue, K.K., Lee, K.W., Chan, K.K., Leung, K.S., Leung, A.W., Cheng, C.H., 2006. Danshen prevents the occurrence of oxidative stress in the eye and aorta of diabetic rats without affecting the hyperglycemic state. Journal of Ethnopharmacology 106, 136–141. Zhang, C., Wu, Z.K., 2008. Molecular pharmacological basis of the YiSui ShenXu Granule in beta-thalassemia therapy. Journal of Ethnopharmacology 120, 437–441. Zhang, L., Zhao, F., Yang, Y., Qi, L., Zhang, B., Wang, F., Wang, S., Liu, L., Wang, H., 2007. Association between carotid artery intima-media thickness and earlystage CKD in a Chinese population. American Journal of Kidney Diseases 49, 786–792. Zhen, H.-X., Zhang, W., Tao, X.-J., Yu, J.-N., Wang, Y.-J., 2010. The Progress in the Research of TCM syndrome patterns in Chronic Renal Failure Zhejiang. Journal of Integrated Traditional Chinese and Western Medicine 20, 330–331. Zheng, C.X., Chen, Z.H., Zeng, C.H., Qin, W.S., Li, L.S., Liu, Z.H., 2008. Triptolide protects podocytes from puromycin aminonucleoside induced injury in vivo and in vitro. Kidney International 74, 596–612. Zhu, B., Lin, Y., Zhu, C.F., Zhu, X.L., Huang, C.Z., Lu, Y., Cheng, X.X., Wang, Y.J., 2011. Emodin inhibits extracellular matrix synthesis by suppressing p38 and ERK1/2 pathways in TGF-beta1-stimulated NRK-49F cells. Molecular Medicine Report 4, 505–509. Zhu, B., Wang, Y.J., Zhu, C.F., Lin, Y., Zhu, X.L., Wei, S., Lu, Y., Cheng, X.X., 2010. Triptolide inhibits extracellular matrix protein synthesis by suppressing the Smad2 but not the MAPK pathway in TGF-beta1-stimulated NRK-49F cells. Nephrology, Dialysis, Transplantation 25, 3180–3191. Zuo, C., Xie, X.S., Qiu, H.Y., Deng, Y., Zhu, D., Fan, J.M., 2009. Astragalus mongholicus ameliorates renal fibrosis by modulating HGF and TGF-beta in rats with unilateral ureteral obstruction. Journal of Zhejiang University Science B 10, 380–390.