Shenkang injection for the treatment of acute kidney injury: a systematic review and meta-analysis.

OBJECTIVE: Shenkang injection (SKI) has been widely used in China for many years for the treatment of kidney disease. The objective of this systematic review was to assess the efficacy of Shenkang injection for the treatment of acute kidney injury (AKI). METHODS: A search was conducted across seven databases, encompassing data from the inception of each database through October 8th, 2023. Randomized controlled trials comparing SKI-treated AKI patients with control subjects were extracted. The main outcome measure was serum creatinine (SCr) levels. Secondary outcomes included blood urea nitrogen (BUN), serum cystatin C (CysC), 24-h urine protein (24 h-Upro) levels, APACHE II score and adverse reactions. RESULTS: This meta-analysis included eleven studies, and the analysis indicated that, compared with the control group, SKI significantly decreased SCr [WMD = -23.31, 95% CI (-28.06, -18.57); p < 0.001]; BUN [WMD = -2.07, 95% CI (-2.56, -1.57); p < 0.001]; CysC [WMD = -0.55, 95% CI (-0.78, -0.32), p < 0.001]; 24-h urine protein [WMD = -0.43, 95% CI (-0.53, -0.34), p < 0.001]; and the APACHE II score [WMD = -3.07, 95% CI (-3.67, -2.48), p < 0.001]. There was no difference in adverse reactions between the SKI group and the control group [RR = 1.32, 95% CI (0.66, 2.63), p = 0.431]. CONCLUSION: The use of SKI in AKI patients may reduce SCr, BUN, CysC, 24-h Upro levels, and APACHE II scores in AKI patients. The incidence of adverse reactions did not differ from that in the control group. Additional rigorous clinical trials will be necessary in the future to thoroughly evaluate and establish the effectiveness of SKI in the treatment of AKI.

Renal Metabolomics Study and Critical Pathway Validation of Shenkang Injection in the Treatment of Chronic Renal Failure.

To reveal the mechanism of Shenkang injection (SKI) in the treatment of chronic renal failure, and verify the key pathway. In this work, an untargeted metabolomics approach was performed by LC-MS coupled with multivariate statistical analysis to provide new insights into therapeutic mechanism of SKI. Hematoxylin-eosin (H&E) Staining and Immunohistochemistry were used to evaluate the effects of drug treatment, Western blot was used to verify the critical pathway. Then, a total of 44 potential biomarkers of chronic renal failure (CRF) were identified and reversed regulation, including 2,8-dihydroxypurine, 5-methoxytryptophan, uric acid, acetylcarnitine, taurine, etc. Mainly concerned with arginine and proline metabolism, purine metabolism, histidine metabolism, etc. Pathological examination showed that the renal interstitium of SKI group was significantly improved, with fewer inflammatory cells and thinner vascular walls compared with the model group. Immunohistochemical results showed that the expression of α-smooth muscle actin (α-SMA) was decreased, and the expression of E-cadherin was increased in CRF model group, and the two indicators were reversed regulation in SKI injection, indicating that the degree of fibrosis was relieved. Critical signaling pathway phosphatidylinositol 3-kinase (PI3K)/protein kinase B (Akt) and nuclear factor-kappaB (NF-κB) protein expressions were significantly inhibited. This study was the first to employ metabolomics to elucidate the underlying mechanisms of SKI in chronic renal failure. The results would provide some support for clinical application of traditional Chinese medicines in clinic.

Pharmacokinetic-pharmacodynamic modeling of the active components of Shenkang injection in rats with chronic renal failure and its protective effect on damaged renal cells.

The study aimed to explore the pharmacokinetic and pharmacodynamic alterations of the active components of Shenkang injection (i.e. hydroxy saffron yellow pigment A [HSYA], tanshinol, rheum emodin, and astragaloside IV) in rats with chronic renal failure (CRF), and establish a pharmacokinetic-pharmacodynamic model (PK-PD model) in order to provide a scientific and theoretical basis for the rational clinical use of Shenkang injection. Sprague-Dawley (SD) rats were randomly divided into a normal group, model group, and Shenkang injection group. A rat model of CRF was induced by adenine gavage and then followed by drug administration via tail vein injection. Orbital blood was collected at different timepoints and the blood concentrations of the four active components were measured by UHPLC-Q-Orbitrap HRMS. Serum levels of creatinine (Scr), urea nitrogen (BUN), and uric acid (UA) were determined using an automatic biochemical analyzer. A PK-PD model was established, and DAS 3.2.6 software was used for model fitting as well as statistical analysis. TGF-ß1 was utilized to induce normal rat kidney cells to construct a renal fibrosis model to investigate the protective effect of the pharmacological components on renal fibrosis. The pharmacokinetic analysis of hydroxy saffron yellow pigment A, tanshinol, rheum emodin, and astragaloside IV based on UHPLC-Q-Orbitrap HRMS was stable. The linear regression equations for the four active components were as follows: Y = 0.031X + 0.0091 (R2  = 0.9986) for hydroxy saffron yellow pigment A, Y = 0.0389X + 0.164 (R2  = 0.9979) for tanshinol, Y = 0.0257X + 0.0146 (R2  = 0.9973) for rheum emodin, and Y = 0.0763X + 0.0139 (R2  = 0.9993) for astragaloside IV, which indicated good linear relationships. The methodological investigation was stable, with the interday and intraday precision RSD <10%. Meanwhile, the recoveries ranged between 90% and 120%, in accordance with the requirements for in vivo analysis of drugs. Compared with the model group, the levels of Scr, BUN, and UA were significantly decreased after 20 min in the Shenkang injection group (p < 0.01). The PK-PD model showed that the four active components in the Shenkang injection group could fit well with the three effect measures (i.e. Scr, BUN, and UA), with the measured values similar to the predicted values. The cell model of renal fibrosis showed that the connective tissue growth factor and FN1 protein expression levels were significantly lower in the Shenkang injection group than those in the model group, and the cell fibrosis was improved. The established method for in vivo analysis of Shenkang injection was highly specific, with good separation of the components and simple operation. The total statistical moment could well integrate the pharmacokinetic parameters of the four active components. After treatment with Shenkang injection, all indexes in the administered group improved and showed significant inhibition of renal cell fibrosis in vitro. This study could provide scientific reference ideas for the clinical rational use of traditional Chinese medicine.

Shenkang protects renal function in diabetic rats by preserving nephrin expression.

BACKGROUND: Shenkang injection has been used clinically to lower creatinine levels. This study explored the mechanism of Shenkang injection on protecting kidney function from hyperglycemia-mediated damage. METHODS: This study utilized a STreptoZotocin (STZ)-induced rat model of diabetes. In total, 60 rats were randomized into either the control group (n = 15) injected with vehicle or treatment group (n = 45) injected with STZ to induce hyperglycemia. Eight weeks after diabetes onset, diabetic rats were further randomized to receive different treatments for 4 consecutive weeks, including vehicle (diabetic nephropathy group, n = 15), Shenkang (n = 15), or Valsartan (n = 15). At 12 weeks, a series of urine and blood measures were examined and damage to the kidney tissue was examined using histology. Expression of nephrin and transforming growth factor-ß1 (TGF-ß1) were characterized using immunohistochemistry and Western blot. RESULTS: Compared to the control group, rats in the diabetic nephropathy group showed significant kidney damage demonstrated by high kidneyindex, high levels of urinary albumin, albumin/creatinine ratio (ACR), blood urea nitrogen as well as histological evidence. Shenkang injection significantly improved kidney function in the diabetic rats by decreasing kidney index, ACR, and serum creatinine. Shenkang treatment also mitigated kidney damage, improved nephrin expression, and decreased TGF-ß1 expression in the kidneys. CONCLUSIONS: Shenkang treatment protected renal function in diabetic rats by increasing nephrin expression, which protects diabetic rats from hyperglycemia-mediated kidney damage.

Network pharmacology-based study on the mechanism of ShenKang injection in diabetic kidney disease through Keap1/Nrf2/Ho-1 signaling pathway.

OBJECTIVE: To study the effect of ShenKang Injection (SKI) on the kidneys of DKD rats and its effect on oxidative stress mediated by the Keap1/Nrf2/Ho-1 signaling pathway through network pharmacology and in vivo and in vitro experiments. METHODS: SKI drug targets were screened by TCMSP, DKD targets were screened by GenGards, OMIM, Drugbank, TTD, and Disgenet databases, and the two intersected for PPI network analysis and target prediction was performed by GO and KEGG. A total of 40 SD rats were randomly divided into 10 in the control group and 30 in the model group. After the model group was fed 8 W with high-sugar and high-fat diets, a DKD model was constructed by one-time intraperitoneal injection of streptozotocin (35 mg/kg). According to the weight, the model animals were randomly divided into three groups: 8 for model validation group, 8 for Irbesartan (25 mg/kg daily) group, and 8 for SKI group (5 ml/kg). Gavaged deionized water was given to the control group and the model validation group equally. The general conditions of the rats were observed, their body weights measured and their urine volumes recorded for 24 h. After the intervention of 16 W, serum was collected to detect Urea, Scr, blood lipids, and oxidative stress and lipid peroxidation indicators; Transmission electron microscopy, HE and Mallory staining were used to observe the pathological morphology of renal tissue. Immunohistochemistry and RT-PCR were used to detect the expression of Keap1, Nrf2, Ho-1, Gpx4 proteins and mRNA in rat kidney tissues. HK-2 cells were cultured in vitro and divided into: the control group, AGEs (200 µg/ml) group and AGEs + SKI group. The cell activity of the groups was detected using CCK-8 after 48 h of cell culture, and ROS were detected using fluorescent probes. Gpx4 expression was detected by immunofluorescence, while Keap1, Nrf2, Ho-1, and Gpx4 were detected by Western Blot. RESULTS: Network pharmacological analysis predicted that SKI may delay DKD kidney injury by affecting redox-related signaling pathways and mitigating AGEs-induced oxidative stress. In the animal experiment, compared with the model validation group, the general state of rats in the SKI group was improved, and 24-hour urine protein levels were significantly reduced, and the Scr in the serum was reduced. A decreasing trend was seen in Urea, and TC, TG, and LDL levels significantly decreased and the levels of ROS, LPO and MDA were significantly lowered. Pathological staining showed that renal interstitial fibrosis was significantly improved, and electron microscopy showed that foot process effacement was alleviated. Immunohistochemistry and RT-PCR showed decreased expression of Keap1 protein and mRNA in kidney tissues of the SKI group. Additionally, Nrf2, Ho-1, and Gpx4 proteins and mRNA were expressed significantly. In the cell experiment, after 48 h treatment with AGEs, ROS in HK-2 cells increased significantly and cell activity decreased significantly, while cell activity in AGEs + SKI group increased significantly and ROS decreased. The expression of Keap1 protein in HK-2 cells in the AGEs + SKI group decreased, while the expression of Nrf2, Ho-1 and Gpx4 proteins increased significantly. CONCLUSION: SKI can protect kidney function in DKD rats, delay DKD progression, inhibit AGEs-induced oxidative stress damage in HK-2 cells, and the mechanism of SKI to improve DKD may be achieved by activating the Keap1/Nrf2/Ho-1 signal transduction pathway.

Shenkang injection combined with alprostadil for chronic renal failure: A systematic review and meta-analysis.

Objective: To systematically evaluate the clinical efficacy and safety of Shenkang injection (SKI) combined with alprostadil in the treatment of chronic renal failure (CRF). Method: Randomized controlled trials (RCTs) of Shenkang injection combined with alprostadil in CRF treatment were investigated by retrieving a total of 7 databases including CNKI, Wanfang database, VIP, CBM, PubMed, Embase and Cochrane Library, with the search time ranging from 2012 to now. Revman 5.2 software was used for data analysis, and Cochrane bias risk tool was used to evaluate the quality of the included literature. The final results were represented by relative risk (RR), mean difference (MD) and 95% confidence interval (95% CI). Results: A total of 20 RCTs and 1,573 patients were included in this study. Meta-analysis showed that the overall response rate (ORR) of the treatment group was superior to the control group [RR = 0.20, 95% CI (0.16, 0.25), P < 0.00001]. Compared with the control group, the treatment group achieved favorable improvement in terms of the creatinine clearance rate (Ccr) [MD = 9.48, 95% CI (8.73, 10.24), P < 0.00001], serum creatinine (Scr) [MD = -55.12, 95% CI (-63.42, -46.82), P < 0.00001], quantitative urine protein (Upro) [MD = -0.48, 95% CI (-0.53, -0.43), P < 0.00001], and blood urea nitrogen (BUN) [MD=-3.73, 95% CI (-4.08, -3.3) 7, P < 0.00001]. There was no statistical difference in the incidence of adverse reactions in each group. Conclusion: Currently, Shenkang injection combined with alprostadil has been widely used in clinical treatment of CRF due to the certain effect superior to other methods. However, its specific efficacy and safety need to be further verified through numerous large-scale clinical trials.

Therapeutic effect and underlying mechanism of Shenkang injection against cisplatin-induced acute kidney injury in mice.

ETHNOPHARMACOLOGICAL RELEVANCE: Shenkang injection (SKI), a Chinese patent medicine injection, has been approved for the treatment of chronic kidney disease (CKD) due to its definite clinical therapeutic efficacy. However, the effect and associated underlying mechanism of Shenkang injection against cisplatin (CDDP)-induced acute kidney injury (AKI) has not yet been well elucidated. AIM OF THE STUDY: This study aims to investigate the therapeutic effect and associated underlying mechanism of Shenkang injection against CDDP-induced AKI. MATERIALS AND METHODS: We established a CDDP-induced AKI mouse model to evaluate renal function by biochemical markers measurement and to observe histopathological alterations by haemotoxylin and eosin (HE)-staining sections of renal. In addition, the distribution of representative components of SKI in the kidneys of mice was evaluated by liquid chromatography tandem mass spectrometry (LC-MS/MS). Furthermore, the degree of oxidative stress and inflammation were assessed by detecting the levels of inflammatory cytokines and oxidants, while the related mechanisms were elucidated by network pharmacology. RESULTS: CDDP could induce excessive inflammation and severe injury to the kidneys of mice. However, SKI significantly ameliorated the kidney damages and improved the renal function by reducing the levels of renal function markers (SCr, BUN and urine protein), and inhibiting the production of inflammatory cytokines IL-34, IL-6 and TNF-α. SKI repaired oxidative balance through up-regulation of antioxidants SOD and GSH and down-regulated oxidants MDA. Moreover, 4 components from SKI were detected in the kidney by LC-MS/MS quantification. In addition, pharmacology network indicated the PI3K/AKT, TNF, MAPK, and p53 were the possible signaling pathways for the therapeutic effect of SKI against CDDP-induced AKI, which were related to inflammation, oxidative stress and apoptosis. CONCLUSION: In the present study, we for the first time demonstrated that SKI alleviates CDDP-induced nephrotoxicity by antioxidant and anti-inflammation via regulating PI3K/AKT, MAPK, TNF, and p53 signaling pathways. The study may provide a scientific rationale for the clinical indication of SKI.

Regulation of the TGF-β type I Receptor/Smad Pathway Inhibits Renal Fibrosis by Shenkang Injection / 世界科学技术-中医药现代化

Objective Chinese herbal injections called Shenkang injections(SKI)have become widely used for treating chronic kidney disease in the clinic.An investigation into the underlying mechanisms of SKI inhibition of renal tubular epithelial cell trans differentiation treated with TGF-β1 was carried out in this study.Methods To create an in vitro model of RF,HK-2 cells were treated with TGF-1(10 ng·mL-1)at 37℃for 48 h.After the cells were treated with SKI for 48 h,the morphology of the cells was observed by electron microscope.And Western blot,RT-PCR and immunofluorescence techniques were used to detect α-Smooth muscle actin(α-SMA),type III collagen(COI-Ⅲ),TGF-β1,Smad3,Smad7 and TβR-I expression changes of proteins and genes.Results SKI can significantly reduce expressed proteins and genes related to renal fibrosis,such as α-Smooth muscle actin(α-SMA)and type Ⅲ collagen(COI-Ⅲ).SKI control the production of proteins associated with the TGF-β/Smad signaling pathway.By downregulating TGF-β1,Smad3,and TβR-I protein expression,as well as upregulating Smad7 protein expression,it is able to prevent cell trans differentiation.Conclusions SKI can inhibit renal tubular epithelial cell mesenchymal trans differentiation.In addition,this drug may prevent chronic kidney disease by downregulating the expression of TβR-I and regulating the TGF-β/Smad pathway-related molecules.

Shenkang injection improves chronic kidney disease by inhibiting multiple renin-angiotensin system genes by blocking the Wnt/ß-catenin signalling pathway.

Chronic kidney disease (CKD) is a major worldwide public health problem. The increase in the number of patients with CKD and end-stage kidney disease requesting renal dialysis or transplantation will progress to epidemic proportions in the next several decades. Although blocking the renin-angiotensin system (RAS) has been used as a first-line standard therapy in patients with hypertension and CKD, patients still progress towards end-stage kidney disease, which might be closely associated with compensatory renin expression subsequent to RAS blockade through a homeostatic mechanism. The Wnt/ß-catenin signalling pathway is the master upstream regulator that controls multiple intrarenal RAS genes. As Wnt/ß-catenin regulates multiple RAS genes, we inferred that this pathway might also be implicated in blood pressure control. Therefore, discovering new medications to synchronously target multiple RAS genes is necessary and essential for the effective treatment of patients with CKD. We hypothesized that Shenkang injection (SKI), which is widely used to treat CKD patients, might ameliorate CKD by inhibiting the activation of multiple RAS genes via the Wnt/ß-catenin signalling pathway. To test this hypothesis, we used adenine-induced CKD rats and angiotensin II (AngII)-induced HK-2 and NRK-49F cells. Treatment with SKI inhibited renal function decline, hypertension and renal fibrosis. Mechanistically, SKI abrogated the increased protein expression of multiple RAS elements, including angiotensin-converting enzyme and angiotensin II type 1 receptor, as well as Wnt1, ß-catenin and downstream target genes, including Snail1, Twist, matrix metalloproteinase-7, plasminogen activator inhibitor-1 and fibroblast-specific protein 1, in adenine-induced rats, which was verified in AngII-induced HK-2 and NRK-49F cells. Similarly, our results further indicated that treatment with rhein isolated from SKI attenuated renal function decline and epithelial-to-mesenchymal transition and repressed RAS activation and the hyperactive Wnt/ß-catenin signalling pathway in both adenine-induced rats and AngII-induced HK-2 and NRK-49F cells. This study first revealed that SKI repressed epithelial-to-mesenchymal transition by synchronously targeting multiple RAS elements by blocking the hyperactive Wnt/ß-catenin signalling pathway.

Shenkang Injection for Treating Renal Fibrosis-Metabonomics and Regulation of E3 Ubiquitin Ligase Smurfs on TGF-ß/Smads Signal Transduction.

At present, TGF-ß is the most critical fibrogenic factor known. Smad ubiquitin ligase Smurfs play an important role in the regulation of the TGF-/Smads signaling pathway, which is linked to metabolite changes in renal fibrosis. Previous studies have shown that Shenkang injection can prevent and treat chronic kidney disease through multiple channels of action. However, the precise relationship between Shenkang injection and the regulation of the TGF-/Smads signaling pathway in the treatment of chronic kidney disease is unknown. Here, we evaluated the pharmacological effects of Shenkang injection on ubiquitination and metabolic changes of the TGF-ß/Smads signaling pathway in UUO mice using pathology-related indicators, immunoprecipitation, subcellular co-location, and metabonomics analysis. Our findings indicate that Shenkang injection can promote nuclear translocation of Smurf1 and Smurf2 to TGF- membrane receptors TR-I and Smad2 and ubiquitinated degradation of these proteins. Furthermore, the formation of TßR-I/TßR-II, TßR-I/Smad2, and TßR-I/Smad3 complexes was inhibited to negatively regulate the TGF-ß/Smad signaling pathway induced renal tubular epithelial transdifferentiation (EMT). The EMT process is not very relevant in vivo, although it is clear that TGF-ß induces EMT in cultured cells, which has been demonstrated by numerous teams around the world. However, this is not the case with the in vivo models of kidney fibrosis, especially UUO. In addition, Shenkang injection can improve amino acid metabolism, purine metabolism, and fatty acid metabolism disorders.

Shenkang injection protects against renal fibrosis by reducing perforin expression through the STING/TBK1/IRF3 signaling pathways in natural killer cells.

BACKGROUND: Immune activation, chronic inflammation, and renal interstitial fibrosis (RIF) are associated with chronic kidney disease (CKD). The herbal formula, Shenkang injection (SKI), has been reported to attenuate RIF. However, the mechanisms by which SKI alleviates renal fibrosis, especially the role of natural killer (NK) cells, are unknown and require exploration. PURPOSE: This study aimed to determine the mechanisms by which SKI alleviates RIF. METHODS: Differential gene expression between CKD mice and control groups was explored using bioinformatics analysis. To reveal how SKI reduces RIF in CKD, a CKD mouse model was established using folic acid for in vivo studies, and human kidney-2 cells were used for in vitro experiments. The effects of various SKI doses were then determined. Immunohistochemical staining, Enzyme-linked immunosorbent assay, western blotting, and quantitative real-time PCR were used for pathological and molecular expression detection. RESULTS: We first investigated the potential immune dysfunction in CKD using bioinformatics analysis. Some differentially expressed genes were enriched in immune-related functions. The expressions of perforin and interferon (IFN)-γ, which are mainly released by NK cells, were significantly higher in patients with CKD (p< 0.05). In vivo experiments showed that SKI alleviated renal fibrosis in a folic acid-induced renal fibrosis model. Serum creatinine and blood urea nitrogen levels were reduced in the high-dose SKI-treated group. Additionally, the mRNA and protein expression levels of type IV collagen and alpha-spinal muscular atrophy were reduced. Biochemical detection showed that SKI could also downregulate the activity of NK cells (by decreasing the expressions of perforin and IFN-γ). Increased levels of stimulator of interferon genes (STING)/TANK-binding kinase 1 (TBK1)/IFN regulatory factor 3 (IRF3), phosphorylation of TBK1, and IRF3 in FA-induced RIF mice were alleviated by SKI treatment, which was consistent with the results of in vitro experiments. CONCLUSION: These results demonstrated that SKI could decrease the activation of NK cells via the STING/TBK1/IRF3 signaling pathway, thereby alleviating RIF and protecting renal function in CKD. This may provide valuable evidence supporting the clinical use of SKI in the treatment of patients with CKD.

Inhibition of Renal Tubular Epithelial Mesenchymal Transition and Endoplasmic Reticulum Stress-Induced Apoptosis with Shenkang Injection Attenuates Diabetic Tubulopathy.

Background: The proximal renal tubule plays a critical role in diabetic kidney disease (DKD) progression. Early glomerular disease in DKD triggers a cascade of injuries resulting in renal tubulointerstitial disease. These pathophysiological responses are collectively described as diabetic tubulopathy (DT). Thus, therapeutic strategies targeting DT hold significant promise for early DKD treatment. Shenkang injection (SKI) has been widely used to treat renal tubulointerstitial fibrosis in patients with chronic kidney disease in China. However, it is still unknown whether SKI can alleviate DT. We designed a series of experiments to investigate the beneficial effects of SKI in DT and the mechanisms that are responsible for its effect on epithelial-to-mesenchymal transition (EMT) and endoplasmic reticulum (ER) stress-induced apoptosis in DT. Methods: The modified DKD rat models were induced by uni-nephrectomy, streptozotocin intraperitoneal injection, and a high-fat diet. Following the induction of renal injury, these animals received either SKI, rosiglitazone (ROS), or vehicle, for 42 days. For in vitro research, we exposed NRK-52E cells to high glucose (HG) and 4-phenylbutyric acid (4-PBA) with or without SKI or ROS. Changes in parameters related to renal tubular injury and EMT were analyzed in vivo. Changes in the proportion of apoptotic renal tubular cells and ER stress, and the signaling pathways involved in these changes, were analyzed both in vivo and in vitro. Results: SKI and ROS improved the general condition, the renal morphological appearance and the key biochemical parameters, and attenuated renal injury and EMT in the rat model of DKD. In addition, SKI and ROS alleviated apoptosis, inhibited ER stress, and suppressed PERK-eIF2α-ATF4-CHOP signaling pathway activation both in vivo and in vitro. Notably, our data showed that the regulatory in vitro effects of SKI on PERK-eIF2α-ATF4-CHOP signaling were similar to those of 4-PBA, a specific inhibitor of ER stress. Conclusion: This study confirmed that SKI can alleviate DT in a similar manner as ROS, and SKI achieves this effect by inhibiting EMT and ER stress-induced apoptosis. Our findings thereby provide novel information relating to the clinical value of SKI in the treatment of DT.

Shenkang Injection and Its Three Anthraquinones Ameliorates Renal Fibrosis by Simultaneous Targeting IƙB/NF-ƙB and Keap1/Nrf2 Signaling Pathways.

Oxidative stress and inflammation are important and critical mediators in the development and progression of chronic kidney disease (CKD) and its complications. Shenkang injection (SKI) has been widely used to treat patients with CKD. Although the anti-oxidative and anti-inflammatory activity was involved in SKI against CKD, its bioactive components and underlying mechanism remain enigmatic. A rat model of adenine-induced chronic renal failure (CRF) is associated with, and largely driven by, oxidative stress and inflammation. Hence, we identified the anti-oxidative and anti-inflammatory components of SKI and further revealed their underlying mechanism in the adenine-induced CRF rats. Compared with control rats, the levels of creatinine, urea, uric acid, total cholesterol, triglyceride, and low-density lipoprotein cholesterol in serum were significantly increased in the adenine-induced CRF rats. However, treatment with SKI and its three anthraquinones including chrysophanol, emodin, and rhein could reverse these aberrant changes. They could significantly inhibit pro-fibrotic protein expressions including collagen I, α-SMA, fibronectin, and vimentin in the kidney tissues of the adenine-induced CRF rats. Of note, SKI and rhein showed the stronger inhibitory effect on these pro-fibrotic protein expressions than chrysophanol and emodin. Furthermore, they could improve dysregulation of IƙB/NF-ƙB and Keap1/Nrf2 signaling pathways. Chrysophanol and emodin showed the stronger inhibitory effect on the NF-κB p65 protein expression than SKI and rhein. Rhein showed the strongest inhibitory effect on p65 downstream target gene products including NAD(P)H oxidase subunits (p47phox, p67phox, and gp91phox) and COX-2, MCP-1, iNOS, and 12-LO in the kidney tissues. However, SKI and rhein showed the stronger inhibitory effect on the significantly downregulated anti-inflammatory and anti-oxidative protein expression nuclear Nrf2 and its target gene products including HO-1, catalase, GCLC, and NQO1 in the Keap1/Nrf2 signaling pathway than chrysophanol and emodin. This study first demonstrated that SKI and its major components protected against renal fibrosis by inhibiting oxidative stress and inflammation via simultaneous targeting IƙB/NF-ƙB and Keap1/Nrf2 signaling pathways, which illuminated the potential molecular mechanism of anti-oxidative and anti-inflammatory effects of SKI.

A review on the efficacy and mechanism of action of Shenkang injection against chronic kidney disease.

Chronic kidney disease (CKD) is one of the most common conditions which significantly increases the risk for serious health outcomes. Epidemiological investigations have shown that CKD has become a serious global health problem. At present, there are no treatments for CKD, thus the need for an effective and safe treatment for this condition. Shenkang Injection (SKI), which is an herbal medication in Chinese Medicine, has been used in the management and treatment of CKD and has achieved favorable therapeutic effects. The purpose of this paper is to review the clinical efficacy, mechanism of action, and safety profile of SKI when used in CKD, and to provide comprehensive potential evidence for its clinical application.

Pharmacokinetics and Metabolism Research of Shenkang Injection in Rats Based on UHPLC-MS/MS and UHPLC-Q-Orbitrap HRMS.

PURPOSE: Shenkang injection, a traditional Chinese herbal prescription, had been widely used in renal disease due to its perfect curative effect. In this research, a novel, sensitive, accurate and rapid liquid chromatography-tandem mass spectrometric method was developed to simultaneously detect the seven active ingredients in rat plasma of Shenkang injection and investigate its pharmacokinetic behaviors with metabolism profiling meanwhile. METHODS: For accurate pharmacokinetic quantitation, a WATERS ACQUITY UPLC® BEH C18 column was used to perform a separation and acetonitrile-water (0.1% formic acid) was selected as mobile phase for gradient elution with a flow rate of 0.20 mL/min. A heated electrospray ionization with selective reaction monitoring mode was used to monitor the precursor-product ion transitions for all the analytes and IS. RESULTS: They all showed good linearity over a wide concentration range (r>0.996 3) and the lower limit of quantification (LLOQ) was 0.1-1.0 ng/mL for analytes. The validation parameters were all within the acceptable limits. Furthermore, for metabolism profiling study, metabolites of the seven ingredients were identified from the rat plasma based on the accurate mass and fragment ions. The metabolic pathways mainly focus on reduction, dehydration and conjugation. CONCLUSION: This study provided an overview of disposition of Shenkang injection, which is highly instructive for better understanding the effectiveness and toxicity of this drug.

Shenkang Injection protects against diabetic nephropathy in streptozotocin (STZ)-induced mice through enhancement of anti-oxidant and anti-inflammatory activities.

Objective: To investigate the protective effects and possible mechanisms of Shenkang Injection (SKI) on the diabetic nephropathy in streptozotocin-induced mice. Methods: STZ with the feeding of high fat diet (HFD) was used to induce diabetic mice. The balb/c mice and diabetic mice were then randomly divided into five groups: (1) control group, (2) model group, (3) alprostadil (Alp, 1.5 µg/kg) group, (4) SKI (30 ml/kg) group, (5) Alp (1.5 µg/kg) + SKI (15 ml/kg) group. After six weeks' treatment, blood, urine and kidney tissues were collected for biochemical assay, ELISA assay, and pathological analysis. Results: Diabetic mice exhibited evident manifestations of diabetic nephropathy (DN), as indicated by increased 24-h urine volume, urinary albumin and kidney weight index (P < 0.01), which could be attenuated by SKI treatment (P < 0.01). SKI was further found to improve abnormal morphology in glomerulus with increased glomerular volume and to decrease urinary N-acetyl-b-D-glucpsaminidase (NAG), ß2-microglobulin (ß2-MG), and kidney injury molecules-1 (KIM-1) levels (P < 0.05, P < 0.01). Plasma levels of anti-oxidant enzymes significantly reduced in the diabetic mice, and those decreases could be reversed by SKI and Alp treatments. Additionally, SKI obviously suppressed the diabetes-induced increases of pro-inflammatory cytokines (IL-6, IL-1ß and TNF-α) (P < 0.01). Meanwhile, SKI was found to effectively attenuate the diabetes-induced coagulation dysfunction, as evidenced by lengthening prothrombin and thrombin time, and decreasing plasma levels of fibrinogen (FIB), 6-K-PGF1α and thromboxane B2 (TXB2) (P < 0.05, P < 0.01). With SKI and Alp combined treatment, the anti-oxidant activities and improvements of coagulation dysfunction were enhanced. Conclusion: SKI possesses a remarkable property to prevent diabetic nephropathy. The improvements of kidney function and hypercoagulability by SKI were enhanced with Alp combined treatment. The molecular mechanisms underlying the protection of SKI against DN may be related to enhancing the anti-oxidant and anti-inflammatory activities, and improving the coagulation dysfunction.

Shenkang Injection protects against diabetic nephropathy in streptozotocin (STZ)-induced mice through enhancement of anti-oxidant and anti-inflammatory activities / 中草药·英文版

Objective: To investigate the protective effects and possible mechanisms of Shenkang Injection (SKI) on the diabetic nephropathy in streptozotocin-induced mice. Methods: STZ with the feeding of high fat diet (HFD) was used to induce diabetic mice. The balb/c mice and diabetic mice were then randomly divided into five groups: (1) control group, (2) model group, (3) alprostadil (Alp, 1.5 μg/kg) group, (4) SKI (30 ml/kg) group, (5) Alp (1.5 μg/kg) + SKI (15 ml/kg) group. After six weeks' treatment, blood, urine and kidney tissues were collected for biochemical assay, ELISA assay, and pathological analysis. Results: Diabetic mice exhibited evident manifestations of diabetic nephropathy (DN), as indicated by increased 24-h urine volume, urinary albumin and kidney weight index (P < 0.01), which could be attenuated by SKI treatment (P < 0.01). SKI was further found to improve abnormal morphology in glomerulus with increased glomerular volume and to decrease urinary N-acetyl-b-D-glucpsaminidase (NAG), β2-microglobulin (β2-MG), and kidney injury molecules-1 (KIM-1) levels (P < 0.05, P < 0.01). Plasma levels of anti-oxidant enzymes significantly reduced in the diabetic mice, and those decreases could be reversed by SKI and Alp treatments. Additionally, SKI obviously suppressed the diabetes-induced increases of pro-inflammatory cytokines (IL-6, IL-1β and TNF-α) (P < 0.01). Meanwhile, SKI was found to effectively attenuate the diabetes-induced coagulation dysfunction, as evidenced by lengthening prothrombin and thrombin time, and decreasing plasma levels of fibrinogen (FIB), 6-K-PGF1α and thromboxane B2 (TXB2) (P < 0.05, P < 0.01). With SKI and Alp combined treatment, the anti-oxidant activities and improvements of coagulation dysfunction were enhanced. Conclusion: SKI possesses a remarkable property to prevent diabetic nephropathy. The improvements of kidney function and hypercoagulability by SKI were enhanced with Alp combined treatment. The molecular mechanisms underlying the protection of SKI against DN may be related to enhancing the anti-oxidant and anti-inflammatory activities, and improving the coagulation dysfunction.

Shenkang injection, a modern preparation of Chinese patent medicine, diminishes tubulointerstitial fibrosis in obstructive nephropathy via targeting pericyte-myofibroblast transition.

Shenkang injection (SKI), a modern preparation of Chinese patent medicine, has been widely applied to clinical therapy in the chronic renal failure patients. However, it remains elusive whether SKI can ameliorate tubulointerstitial fibrosis (TIF) in vivo. Recently, pericyte-myofibroblast transition (PMT) plays an important role in the pathogenesis of TIF in obstructive nephropathy (ON). This report thus aims to demonstrate the therapeutic mechanisms of the dose-effects of SKI on TIF by targeting PMT and its signaling activation, compared with imatinib. All rats were divided into 5 groups, the sham-operated group, the vehicle-intervened group, the high dose of SKI-treated group, the low dose of SKI-treated group and the imatinib-treated group. The ON model rats were induced by unilateral ureteral obstruction (UUO), and administered with either the different doses of SKI or imatinib before and after modeling and for a period of 4 weeks. The changes before and after drugs intervention in TIF and PMT markers, and in platelet-derived growth factor receptor (PDGFR) and vascular endothelial growth factor receptor (VEGFR) signaling pathways activation in the kidneys were analyzed, respectively. As a result, PMT trigger was persistently accompanied with TIF exasperation in the obstructed kidneys after UUO, and that SKI definitely targeted PMT and significantly diminished TIF in vivo. In addition, the high dose of SKI, superior to imatinib, specifically blocked PMT through inhibiting the activation of PDGFR and VEGFR signaling in the kidneys of the UUO model rats. Overall, these findings may further suggest that targeting PMT can provide new strategies for ON treatment.

Preventive effect of Shenkang injection against high glucose-induced senescence of renal tubular cells / 医学前沿

Shenkang injection (SKI) is a classic prescription composed of Radix Astragali, rhubarb, Astragalus, Safflower, and Salvia. This treatment was approved by the State Food and Drug Administration of China in 1999 for treatment of chronic kidney diseases based on good efficacy and safety. This study aimed to investigate the protective effect of SKI against high glucose (HG)-induced renal tubular cell senescence and its underlying mechanism. Primary renal proximal tubule epithelial cells were cultured in (1) control medium (control group), medium containing 5 mmol/L glucose; (2) mannitol medium (mannitol group), medium containing 5 mmol/L glucose, and 25 mmol/L mannitol; (3) HG medium (HG group) containing 30 mmol/L glucose; (4) SKI treatment at high (200 mg/L), medium (100 mg/L), or low (50 mg/L) concentration in HG medium (HG + SKI group); or (5) 200 mg/L SKI treatment in control medium (control + SKI group) for 72 h. HG-induced senescent cells showed the emergence of senescence associated heterochromatin foci, up-regulation of P16 and cyclin D1, increased senescence-associated β-galactosidase activity, and elevated expression of membrane decoy receptor 2. SKI treatment potently prevented these changes in a dose-independent manner. SKI treatment prevented HG-induced up-regulation of pro-senescence molecule mammalian target of rapamycin and p66Shc and down-regulation of anti-senescence molecules klotho, sirt1, and peroxisome proliferator-activated receptor-g in renal tubular epithelial cells. SKI may be a novel strategy for protecting against HG-induced renal tubular cell senescence in treatment of diabetic nephropathy.

Shenkang injection improves coagulation in patients with chronic kidney disease: a systematic review and Meta-analysis.

OBJECTIVE: To investigate the effect of Shenkang injection (SKI) on chronic kidney disease (CKD). METHODS: Seven databases including Cochrane Central Register of Controlled Trials, PubMed, EMBASE, MEDLINE, China National Knowledge Infrastructure, Wanfang Database, and CQVIP from their inception to March 2018 were searched. Only randomized controlled trials that evaluated conventional treatment and conventional treatment with SKI in CKD patients were investigated. Outcomes such as fibrinogen (FIB), D-dimer, prothrombin time (PT), activated partial thromboplastin time (APTT), and the side effects of SKI were analyzed using Revman 5.3 software. The quality of the studies was assessed using the Cochrane Collaboration's Risk of Bias tool and the quality of evidence was assessed using GRADEpro. RESULTS: Four randomized controlled trials were investigated in our analysis, and these studies were of moderate quality. For FIB and D-dimer, SKI had a superior effect compared with the control group [mean difference (MD)= －1.23, 95% confidence interval (CI): －1.46, －1.99, P < 0.01; MD = －1.36, 95% CI: －1.51, －1.21, P < 0.01, respectively]. SKI increased APTT and PT compared with the control (MD = 7.34, 95% CI: 3.05, 11.62, P < 0.01; MD = 3.40, 95% CI: 2.2, 4.61, P < 0.01, respectively). In the four studies, there were no side effects that were related to SKI. CONCLUSION: SKI may be effective in improving coagulation in patients with CKD without obvious adverse reactions. However, more well-designed studies are required to confirm the findings.