A Proteomic Approach for the Diagnosis of ‘Oketsu’ (blood stasis), a Pathophysiologic Concept of Japanese Traditional (Kampo) Medicine

‘Oketsu’ is a pathophysiologic concept in Japanese traditional (Kampo) medicine, primarily denoting blood stasis/stagnant syndrome. Here we have explored plasma protein biomarkers and/or diagnostic algorithms for ‘Oketsu’. Sixteen rheumatoid arthritis (RA) patients were treated with keishibukuryogan (KBG), a representative Kampo medicine for improving ‘Oketsu’. Plasma samples were diagnosed as either having an ‘Oketsu’ (n = 19) or ‘non-Oketsu’ (n = 29) state according to Terasawa's ‘Oketsu’ scoring system. Protein profiles were obtained by surface-enhanced laser desorption/ionization time-of-flight mass spectrometry (SELDI-TOF MS) and hierarchical clustering and decision tree analyses were performed. KBG treatment for 4 or 12 weeks decreased the ‘Oketsu’ scores significantly. SELDI protein profiles gave 266 protein peaks, whose expression was significantly different between the ‘Oketsu’ and ‘non-Oketsu’ states. Hierarchical clustering gave three major clusters (I, II, III). The majority (68.4%) of ‘Oketsu’ samples were clustered into one cluster as the principal component of cluster I. The remaining ‘Oketsu’ profiles constituted a minor component of cluster II and were all derived from patients cured of the ‘Oketsu’ state at 12 weeks. Construction of the decision tree addressed the possibility of developing a diagnostic algorithm for ‘Oketsu’. A reduction in measurement/pre-processing conditions (from 55 to 16) gave a similar outcome in the clustering and decision tree analyses. The present study suggests that the pathophysiologic concept of Kampo medicine ‘Oketsu’ has a physical basis in terms of the profile of blood proteins. It may be possible to establish a set of objective criteria for diagnosing ‘Oketsu’ using a combination of proteomic and bioinformatics-based classification methods

Atrasentan and renal events in patients with type 2 diabetes and chronic kidney disease (SONAR): a double-blind, randomised, placebo-controlled trial

Background: Short-term treatment for people with type 2 diabetes using a low dose of the selective endothelin A receptor antagonist atrasentan reduces albuminuria without causing significant sodium retention. We report the long-term effects of treatment with atrasentan on major renal outcomes. Methods: We did this double-blind, randomised, placebo-controlled trial at 689 sites in 41 countries. We enrolled adults aged 18–85 years with type 2 diabetes, estimated glomerular filtration rate (eGFR)25–75 mL/min per 1·73 m 2 of body surface area, and a urine albumin-to-creatinine ratio (UACR)of 300–5000 mg/g who had received maximum labelled or tolerated renin–angiotensin system inhibition for at least 4 weeks. Participants were given atrasentan 0·75 mg orally daily during an enrichment period before random group assignment. Those with a UACR decrease of at least 30% with no substantial fluid retention during the enrichment period (responders)were included in the double-blind treatment period. Responders were randomly assigned to receive either atrasentan 0·75 mg orally daily or placebo. All patients and investigators were masked to treatment assignment. The primary endpoint was a composite of doubling of serum creatinine (sustained for ≥30 days)or end-stage kidney disease (eGFR <15 mL/min per 1·73 m 2 sustained for ≥90 days, chronic dialysis for ≥90 days, kidney transplantation, or death from kidney failure)in the intention-to-treat population of all responders. Safety was assessed in all patients who received at least one dose of their assigned study treatment. The study is registered with ClinicalTrials.gov, number NCT01858532. Findings: Between May 17, 2013, and July 13, 2017, 11 087 patients were screened; 5117 entered the enrichment period, and 4711 completed the enrichment period. Of these, 2648 patients were responders and were randomly assigned to the atrasentan group (n=1325)or placebo group (n=1323). Median follow-up was 2·2 years (IQR 1·4–2·9). 79 (6·0%)of 1325 patients in the atrasentan group and 105 (7·9%)of 1323 in the placebo group had a primary composite renal endpoint event (hazard ratio [HR]0·65 [95% CI 0·49–0·88]; p=0·0047). Fluid retention and anaemia adverse events, which have been previously attributed to endothelin receptor antagonists, were more frequent in the atrasentan group than in the placebo group. Hospital admission for heart failure occurred in 47 (3·5%)of 1325 patients in the atrasentan group and 34 (2·6%)of 1323 patients in the placebo group (HR 1·33 [95% CI 0·85–2·07]; p=0·208). 58 (4·4%)patients in the atrasentan group and 52 (3·9%)in the placebo group died (HR 1·09 [95% CI 0·75–1·59]; p=0·65). Interpretation: Atrasentan reduced the risk of renal events in patients with diabetes and chronic kidney disease who were selected to optimise efficacy and safety. These data support a potential role for selective endothelin receptor antagonists in protecting renal function in patients with type 2 diabetes at high risk of developing end-stage kidney disease. Funding: AbbVie

Japanese and european management/ Malcolm Trevor

xii, 272 hal.; 22 cm

Japanese and european management/ Malcolm Trevor

xii, 272 hal.; 22 cm

Effects of two formulations for overcoming oketsu on vascular function and expression patterns of plasma proteins in spontaneously diabetic rats

自然発症糖尿病モデルであるWBN/Kobラットに代表的な駆瘀血薬である桂枝茯苓丸と当帰芍薬散を長期間投与し, 血管機能とタンパク発現に及ぼす影響を検討した。方法は, WBN/Kobラット(雄, 24週令)を18週間飼育し糖尿病発症を確認した後, 対照群, 3%桂枝茯苓丸(KB)群, 3%当帰芍薬散(TS)群の3群に分け, さらに25週間飼育した。飼育後, 胸部大動脈を摘出しOrgan bath法を用いacetylcholine (Ach)による血管弛緩作用, xanthine/xanthine oxidase (X/XOD)投与による血管収縮作用等を検討した。同時に, 血液流動性, 血漿脂質, NO代謝物等の測定とSELDI-TOF-MSによる血漿プロテオーム解析を施行した。結果は, 対照群とKB, TS群の3群間において, 体重と血糖値に有意な差を認めなかった。Achによる内皮依存性血管弛緩率はKB群で対照群に対し有意に弛緩率の増加を認めた。X/XOD投与による血管収縮率はTS群で, PLA_2投与による血管収縮率はTS, KB群の両群で対照群に対し収縮率の減少を認めた。血液流動性はTS群で対照群に対し改善傾向を認め, NO代謝物はKB, TS群の両群で対照群に対し有意に減少した。血漿プロテオーム解析により, 対照群に比較しKB群では5個, TS群で8個のタンパク質の有意な変動を認めた。以上のことから, 2種類の代表的な駆瘀血薬は, 一部異なる作用機序で血流改善に影響を及ぼし, 発現するタンパク質にも差異が認められた。作用機序とタンパク質発現との関連は今後検討を要するが, これらの多成分系の方剤による生体の複雑な反応性の差異が「証」の成立に影響していると考えられた。We investigated the effects of keishibukuryogan and tokishakuyakusan, which are representative formulations for overcoming oketsu, on vascular function and expression patterns of plasma proteins in spontaneously diabetic rats. Twenty-one- to 24-week-old male WBN/Kob rats were maintained for 18 weeks on a diabetes-accelerated feed, and received standard (diabetes-accelerating) chow containing 3% (wt/wt) keishibukuryogan or tokishakuyakusan for 25 weeks. There was no significant change in body weight or blood glucose among the groups. Acetylcholine-induced endothelium-dependent relaxation of the keishibukuryogan group significantly increased compared to that of controls. Xanthine/xanthine oxidase-induced contraction of the tokishakuyakusan group and phospholipase A_2-induced contraction of the keishibukuryogan and tokishakuyakusan groups significantly decreased compared to the controls. Transit time of whole blood tended to decrease in the tokishakuyakusan group compared to controls. NO_2^-/NO_3^- in the keishibukuryogan and tokishakuyakusan groups significantly decreased compared to controls. A study using surface enhanced laser desorption/ionization time-of-flight mass spectrometry (SELDI-TOF-MS) demonstrated that five and eight peaks had significantly changed peak intensities in plasma of rats treated with keishibukuryogan and tokishakuyakusan, respectively, as compared to the controls. Thus, two representative formulations for overcoming oketsu with different mechanisms of action had favorable effects against vascular dysfunction. Altered plasma protein levels were commonly observed in the rats administered these two formulations. Our study using ProteinChip technology may be useful for the evaluation of the relationship between the efficacy and the profiling of plasma protein expression after administration Kampo medicines, thus leading to the understanding of "Sho" in Kampo medicine.The 21st Century COE Program, Toyama Medical and Pharmaceutical Universit