A review of the prescription containing Hirudo for diabetic nephropathy

Background:Based on the modern literature,this paper discusses the characteristics of the medication and the prescription rules of the prescriptions containing Shuizhi (Hirudo) for diabetic nephropathy.Methods:We searched the China National Knowledge Infrastructure Database,Wanfang Academic Journals Full-text Database,VIP Chinese Journals Database and China Biomedical Literature Database,as well as Pubmed,the Cochrane Library and EMbase.The time limit is from setup time to November 4,2020.Include literatures published in journals containing prescriptions for treating diabetic nephropathy with Hirudo.These data was established a standardized database and then mined these data using association rules,improved mutual information method,complex system entropy clustering and other mining methods with traditional Chinese medicine inheritance auxiliary system (V2.5) software to excavate the characteristics of medication and the rules of prescription.Results:The study finally included 477 literatures,involving 477 prescriptions,235 Chinese medicines,5,552 times of total medicine frequency,and unearthed 20 core formulas and 9 new formula combinations.Among them,high-frequency drugs are Hirudo,HuangQi (Astragali radix),Danshen (Salviae miltiorrhizae radix et rhizoma),Shanyao (Dioscoreae rhizoma),Dahuang (Rhei radix et rhizoma),Shanzhuyu (Corni fructus),Fuli (Poria),Danggui (Angelicae sinensis radix),Shengdihuang (Rehmanniae radix),Chuanxiong (Chuanxiong rhiazoma) et al.The core prescription is a combination of Astragali radix,Hirudo,Dioscoreae rhizoma,Poria,Corni fructus,Angelicae sinensis radix,et al.Conclusion:High-frequency drugs and core prescriptions embody the characteristics of “Replenishing Qi”,“Activating Blood”,and “Nourishing Yin”.The core prescription rules were“Replenishing Qi” and “Activating Blood”.Promoting the circulation of “Qi”,promoting “Urination and Draining”,“Downbearing” the turbid were the auxiliary functions.The unearthed new prescriptions provide new ideas for the combination of prescriptions containing Hirudo in the treatment of diabetic nephropathy.

Key words：Hirudo,Diabetic nephropathy,Modern literature,Medication rule,Data mining

Background

Diabetic nephropathy (DN) is one of the most serious microvascular complications in diabetic patients and one of the main causes of end-stage renal disease [1].The pathogenesis of DN is concealed,but it is easy to deteriorate into end-stage renal disease.At present,the prevalence of DN in my country has been at a high level,which is comparable to the level in moderately developed countries,and is likely to continue to rise,and the number of potential DN patients will increase accordingly [2].

In recent years,it has been discovered that hirudin in is similar to insulin sensitizers,inhibits thrombin and thus has anticoagulant effects.At the same time,hirudin can regulate multiple cytokines such as transforming growth factor beta,vascular endothelial growth factor,connective tissue growth factor,et al.,and reduce tumour necrosis factor alpha in the inflammatory response pathway.Reducing tumour necrosis factor alpha can reduce the expression of the gene Bcl-2 that inhibits cell apoptosis,and effectively improve the clinical symptoms of patients with DN,thereby delaYing the progression of the disease and improving the quality of life of patients [3].Shi et al.[4] observed the presence or absence of leech injection to treat DN,and found that the values of “triglyceride,triglyceride,high density lipoprotein,low density lipoprotein cholesterol,blood specific viscosity,erythrocyte sedimentation rate,high shear rate,low shear rate” and other values in the treatment group added withHirudopreparation decreased.UAE,Scr,BuN and other indicators of renal damage have been improved.Hirudopreparation have improved various indicators and symptoms of DN patients.Li et al.[5]found that the overall effective rate for the DN treatment ofHirudopreparation was 90%.

At present,there is no relevant research on the clinical data of the preparation ofHirudoin the treatment of DN.Therefore,we have sorted out the literatures aboutHirudotreatment of DN,then analyzed these data with the traditional Chinese medicine (TCM) inheritance auxiliary system software.Data mining is further carried out about the characteristics and the prescription rules ofHirudocontaining prescription for the DN treatment.

Materials and methods

Diagnostic criteria

1) The diagnosis of DN complies with the 2019 American Diabetes Association standards [6].2) The diagnosis of DN can satisfy any one of the following:(1) mass albuminuria,and the definition of abnormal urine albumin excretion rate refers to the 2014 “Expert Consensus on Diabetic Nephropathy Prevention” [7];(2) diabetic retinopathy with microalbuminuria; (3)microalbuminuria occurs in type 1 DM patients with a course of more than 10 years.

Literature inclusion and exclusion criteria

Inclusion criteria:①clinical research literature with DN patients as the main research object,including curative effect observation,curative effect analysis,case-control study,et al; ②the treatment prescriptions in the literature must containHuridoand be a compound prescription; ③the literature must have all the drug components of the therapeutic prescription;④the total number of clinical research cases in the literature is 60 or more.

Exclusion criteria:①subjects with other chronic kidney disease damage; ② repeated publication,different names of the same side and repeated reports of the same side; ④ there are only prescription names,no specific drugs or incomplete literature on prescription drugs; ⑤ case reports,empirical discussions,theoretical reviews,systematic reviews,mechanism discussions,animal experiments et al.

Literature sources and retrieval methods

We searched China National Knowledge Infrastructure Database,Wanfang Academic Journals Full-text Database,VIP Chinese Journals Database and China Biomedical Literature Database,as well as the English databases Pubmed,the Cochrane Library and EMbase database.The retrieval time limit is from the setup to November 4,2020.The search terms was “diabetic nephropathy”,“DN”,“Hurido”,“l(fā)eech” and other keywords.

Literature screening and collation

Import the retrieved documents into Note Express software,with the help of software functions.Read the full text carefully,and further exclude and screen the included documents according to the exclusion criteria.

Prescription extraction and database establishment

Extract the data included in the literature,including the cases,the name of the prescription,the composition of the drug,the dose of the drug,et al.The names of Chinese medicines are standardized based on the 2015 edition of theChinese Pharmacopoeia.Use Excel software to build a database containing DN ofHirudotreatment.

Data entry and verification

One researcher is responsible for entering the data into the TCM inheritance auxiliary system software,and another researcher is responsible for checking.A third party to ensure the accuracy and completeness of the data entry will evaluate the disputed documents.

Data analysis

Statistics of drug frequency.Use the “frequency statistics” function in “prescription analysis” to arrange each medicine in all prescriptions in order of frequency from most to least,and export the results to an excel file.

Basic characteristics of the drug.Select the “basic information statistics” module; click the “Four Qi statistics”,“Five Taste statistics” and “return statistics”buttons to export the results in the form of excel files.

Analysis of formulating rules based on association rules.Use the “prescription rule” function in “analysis of prescriptions” to set the number of support to 102 and the confidence to 0.95 respectively,and mine the“drug mode” and “rule analysis”,and export the results to an excel file [8].

New method analysis.Based on entropy clustering and improved mutual information method.Use the“analysis of new formulas” in the “analysis of formulas”,set the correlation to 8 and the penalty to 4,perform cluster analysis,and then click the “extract combination” button to form a new prescription [8].

Results

Results of literature inclusion

Finally,477 literatures containingHuridoin the treatment of DN were included with 477 prescriptions,235 TCMs,and 5,552 the total frequency of drugs.The effective rate ofHuridopreparations was 60%.

Frequency analysis of single drug use

The 477 prescriptions included in the study contained 235 TCMs.According to the frequency statistics,there are 19 medicines with a frequency of not less than 75 times (Table 1).

Basic characteristics of the drug

The 235 Chinese medicines in the 477 prescriptions containingHuridofor DN treatment ranked in descending order of frequency.The distribution characteristics of these drugs are as follows.The“Properties of Flat” (33.29%) ＞ the “Properties of Warm” (31.84%) ＞ the “Properties of Cold”(30.25%) > the “Properties of Cool” (3.84%) ＞ the“Properties of Hot” (0.78%); the “Tastes of Sweet”(38.24%) ＞ the “Tastes of Bitter” (29.10%) ＞ the“Tastes of Pungent” (13.36%) ＞ the “Tastes of Salty”(8.67%) > the Tastes of Acid (5.55%) > the Tastes of Astringent” (5.08%); the top five “Meridians and Collaterals”:the “Liver Meridian” (23.02%) > the“Spleen Meridian” (17.98%) ＞ the “Kidney Meridian”(15.25%) ＞ the “Lung Meridian” (10.99%) ＞ the“Heart Meridian” (12.01%).

Analysis of the rule of prescription

When “support” is set to 140 and “confidence” is set to 0.95,common combinations are obtained,involving 7 kinds of TCM,19 pairs of double drugs,10 combinations of triple drugs and 1 combination of quadruplicate drugs (Table 2).The medication rules for the main drug pairs or drug combinations are shown in Table 3.The network display of high-frequency core drug association rules is shown in Figure 1.

Table 1 Traditional Chinese medicine with a frequency of at least 75 times

New prescription analysis

Use the “analysis of new formulas” in the “analysis of formulas”,set the correlation to 8 and the penalty to 4,and then click the “extract combinations” button to find combinations.The new prescription combination is based on the clustering based on the new prescription and network display based on the monarch,minister,assistant and guide in TCM prescription(Table 4,Table5).Network visualization,see Figure 2,Figure 3.

Table 2 Frequency of commonly used drug pairs (confidence ≥ 140)

Table 3 Commonly used drug combinations (confidence level ≥ 0.95)

Figure 1 Network presentation of commonly used drug combinations (confidence ≥ 140)

Table 4 The prescriptions used for new party cluster

Table 5 The new prescriptions

Figure 2 Network visualization diagram that can be used for new prescription cluster combination

Figure 3 network visualization of new prescription combination

Discussion

BesidesHirudo,the drugs with the highest frequency were Huangqi (Astragali radix),Danshen (Salviae miltiorrhizae radix et rhizoma),Shanyao (Dioscoreae rhizoma),Dahuang (Rhei radix et rhizoma),Shanzhuyu (Corni fructus),Fuli (Poria),Danggui(Angelicaesinensisradix),Shengdihuang(Rehmanniae radix),Zexie (Alismatis Rhizoma),Chuanxiong (Chuanxiong rhiazoma),Shudihuang(Rehmanniae radix praeparata),Yimucao (Leonuri herba),Baizhu (Atractylodis macrocephalae rhizoma),Dilong (Pheretima),Mudanpi (Moutan cortex),Taizishen (Pseudostellariaeradix),Gancao(Glycyrrhizae radix et rhizoma) and GouQizi (Lycii fructus).Among them,Astragali radixandRhei radix et rhizomaare single Chinese medicines recommended in the expert consensus on the prevention and treatment of DN with integrated Chinese and Western medicine (2019) [9].TCM believes that the basic pathogenesis of DN was the “Viscera Qi Internal Deficiency”,mainly the “Qi and Yin Dysfunction”.Under this basic,when “Feeling External Evil”,“Feelings of Internal Injury”,“Excessive Labor”,diet and other causes,resulted in “Cold Coagulation”,“Qi Stagnation”,“Blood Stasis”,“Phlegm” and other pathogenic.“Qi Deficiency” will lead to the physiological function of the “Viscera” can not be normal; “Yin Deficiency” refers to the deficiency of body fluid.In addition to “Qi”,the “Viscera and Organs” also need “Yin Fluid” to nourish,and the lack of body fluid will also lead to abnormal.Astragali radix,as the most frequently used medicine,is one of the most commonly used “Qi TonifYing” drugs.It plays an important role in “TonifYing the Qi of Spleen and Lung”,and solves the “Qi Deficiency” caused by long course of disease and consumption of “Healthy Qi” in patients with DN.“Healthy Qi” is the ability of anti-pathogenic in human body.At the same time,modern pharmacological research shows that astragaloside IV has a protective effect on DN [10].Dioscoreae rhizomahas the effect of “TonifYing Qi”and “Nourishing Yin”,and both “Qi and Yin are TonifYing”.As mentioned before,if the “Qi and Yin”of human body are normal,the function of “Viscera”can better play its physiological role,just in line with the interpretation of DN Chinese medicine prevention and treatment guide [11].Modern pharmacological research has found that polysaccharide inDioscoreae rhizomahas the effect of reducing blood sugar and blood fat [12].Salviae miltiorrhizae radix et rhizoma,Chuanxiong rhiazoma,Angelicae sinensis radixand Sanqi (Notoginseng radix et rhizoma) all have the function of “Promoting Blood Circulation and Removing Blood Stasis”.“Promoting Blood Circulation and Removing Blood Stasis” is to remove“Blood Stasis” in the human body,to promote the vigorous recovery of “Qi and Blood”.“Blood Stasis Syndrome” runs through the early,middle and late stages of DN [13].Overall,high-frequency drugs are mainly for “Supplementing Qi” and “Nourishing Yin”,“Promoting Blood Circulation and Removing Blood Stasis”,and some of them are for “Invigorating the Spleen and Promoting Diuresis”.“Invigorating the Spleen and Promoting Diuresis” is to strengthen the physiological function of the “Spleen” and reduce the function of abnormal water discharged from the body.

The characters of Chinese medicine showed that the overall medicine was mainly “Mild”,and the treatment of “Cold” and “Heat” bias was not obvious,which reflected the thought of TCM“Syndrome Differentiation”.The data show that most of the drugs are “Pungent”,“Sweet” and “Bitter”,and most of the“Sweet” drugs are tonics,while the “Pungent” drugs are “Dispersive”,which can “Disperse the Evil Qi” in the human body.“Meridian Tropism” is the orientation of drug action.The most commonly used drugs can affect the “Liver,Spleen and Kidney Meridians”,which play an important role in the generation and distribution of “Yin Fluid”.Zhang Zhenzhong [14]thinks that in the treatment of DN,“Activating Blood Circulation and Removing Blood Stasis” can be used as an intermediate product to reconcile contradictions,which are all treated from the “Liver meridian”.

The excavation of high-frequency core prescriptions showed that the most frequent two-medicine combination wasHirudoandAstragali radix,which appeared 424 time.This data suggests that the treatment is based on the principle of “Supplementing Qi” and “Activating Blood Circulation”.The combination of the 2 drugs can not only “Supplement Qi” and “Activating Blood Circulation”,but also inhibit the release of inflammatory mediators and cytokines,to reduce the inflammatory reaction and delay the damage of diabetic kidney [15,16].The combination of 3 herbs is based on these 2 herbs,andSalviae miltiorrhizae radix et rhizomais added.The combination appeared 251 times,and “Strengthened Blood Circulation” on the basis of "Replenishing Qi"and "Activating Blood".At the same time,modern pharmacology researchers found thatAstragali radix-Salviaemiltiorrhizaeradixetrhizomacompatibility can affect mitochondrial apoptosis.Affecting the expression of the renin-angiotensin system and inflammatory immune mediators can alleviate the progression of DN and have a certain effect on its complications [17].

The results of association rules analysis showed that the drug combinations with high association degree wereAstragalus membranaceusandHirudo,Astragali radix,Poria,Dioscoreae rhizoma,Rhei radix et rhizoma,et al.In addition,the combination was conducted in the mode of 2,3 or 4 drugs.Among them,Astragali radixandHirudoare the core drugs,and astragalus is used to “Invigorate Qi and Benefit Health” andHirudoto “Break Blood and Remove Blood Stasis”,which is a treatment method that is deeper than “Activating Blood and Removing Blood Stasis”.The overall treatment method is based on“Replenishing Qi and removing Blood Stasis”,and is combined with products for “Promoting Qi,Nourishing Yin and Turbidity” to alleviate the problem.

It can be seen that the high-frequency drugs and core prescriptions are mainly used to “Promote Blood Circulation”,“Replenish Qi”,“Collect Astringent”,and “Nourish Yin”.The prescription rule is to“Replenish Qi and Promote Blood Circulation”.At the same time,DN is “Deficiency of Both Qi and Yin,Obstruction of Kidney Collaterals by Blood Stasis,Inability of Blood Circulation due to Qi Deficiency or Poor Blood Flow due to Yin Deficiency” [18].“Blood Stasis” is an important pathological factor throughout the disease.For the DN treatment,Astragali radixis the first choice,Atractylodis macrocephalae rhizomaand other “Qi Replenishing” drugs were followed,then come theDioscoreae rhizoma,Rehmanniae radix praeparata,Rehmanniae radixand other “Nourishing Yin” drugs.

Nine new prescriptions were obtained in this research,which “Invigorated Qi” and “Strengthened the Body”.Taoren (Persicae semen),Salviae miltiorrhizae radix et rhizoma“Promoted Blood Circulation to Remove Blood Stasis”,combined with dry Ganqi (Toxicodendri resina) to “Strengthen Blood Circulation”,followed the principle of “Replenishing Qi” and “Activating Blood”,and on this basis,it was matched withCorni fructus“Nourishing Yin”.Wang[19] used the method of “Replenishing Qi”,“Activating Blood” and “Nourishing Yin” combined with Western medicine to treat 54 patients with DN,the total effective rate was 92.59%,and the clinical effect was significant.New prescription 2 is to“Detoxify and Dispel Stagnation”.It can be used for patients with “Deficiency of both Qi and Yin and Blood Stasis”.On the basis of the first 2 prescriptions,the new prescription 3 deletes “Qi Reinforcing” drugs and is clinically suitable for patients with “Yin Deficiency and Blood Stasis Syndrome”.The new prescription 4 uses Maidong (Ophiopogonis radix) and Mohanlian (Ecliptae herba) to “Nourish Yin and Kidney”,together with Wuweizi (Schisandrae chinensis fructus) and Jineijin (Galli gigerii endothelium corneum) to keep the body's “Yin Fluid”in the body.At the same time,Zelan (Lycopi herba)“Promotes Blood Circulation and Removes Blood Stasis”.It is suitable for both “Yin Deficiency” and“Blood Stasis”.On the basis of new formula 4,new formula 5 added Cheqiancao (Plantaginis herba) to promote “Diuresis” and “Turbidity”.New recipe 6 is to use Ezhu (Curcumae rhizoma),Baimaogen(Imperatae rhizoma) andNotoginseng radix et rhizomato “Promote Blood Circulation and Remove Blood Stasis”,and Machixian (Portulacae herba) and Xiakucao (Prunellae spica) to “Clear Away Heat and Toxin”.The whole recipe plays the role of “Promoting Blood Circulation and Removing Blood Stasis”,“Clear Away Heat and Toxin”.It is suitable for the“Syndrome of Excessive Heat due to Blood Stasis and Toxin”.On the basis of “Promoting Blood Circulation”and “Detoxification”,the new prescription 7 is combined withYumixu (Corn silk)and Qianshi(Euryales semen) to “Invigorate the Kidney” and“Astringent”.It can be clinically used for patients with“Blood Stasis and Toxin and Kidney Deficiency”.New prescription 8 is Cangzhu (Atractylodis rhizoma),Xuanshen (Scrophulariaeradix) and Gegen(Pueraeiae lobatae radix),which belong to the“Stomach Meridian”,and have the effect of“Nourishing Stomach Yin”.On the basis of the new formula 8,the new formula 9 omits the “Blood Activating” drugs and selects Yiyiren (Coicis semen),Yinyanghuo (Epimedii folium) andBixie (Dioscoreae hypoglaucae rhizoma)to strengthen the“Dehumidification”,which can be used for the patients with “Yin Deficiency” and “Heavy Dampness”.

To sum up,this article uses TCM inheritance auxiliary system software to excavate and analyze the effective prescriptions containingHirudofor the treatment of DN,and clarify the characteristics of its medicines based on “Qi,Blood Circulation and Yin nourishing”.The medication characteristics and prescription rules are presented in the form of specific drugs and drug combinations to make them more intuitive and visible.At the same time,the clinical use of the new prescription and its potential value were preliminarily discussed and demonstrated,which provided a certain reference significance for the compatibility of the prescription containingHirudo.However,the standardization and research level of literature are uneven,and the number of literature is relatively small.Further excavation and further research and verification in the clinic are needed.