Literature study on traditional Chinese medicine syndromes after renal transplantation

Abstract

BACKGROUND

Kidney transplantation is the most effective means to treat patients with renal failure, but its postoperative problems such as rejection reactions, immunosuppressant poisoning, chronic transplant kidney nephropathy, etc. still have not been effectively solved. This study searched for literature on traditional Chinese medicine (TCM) syndromes after kidney transplantation in China, conducted statistical analysis of the results, and sought to identify the underlying patterns.

AIM

To understand the TCM syndromes after renal transplantation and associated rules and provide a theoretical basis for further clinical research.

METHODS

The literature pertaining to TCM syndromes in renal transplantation, published in the China National Knowledge Infrastructure, Wanfang database, and WIP database from 1970 to 2021, was meticulously searched and comprehensively and statistically analyzed.

RESULTS

Following the established inclusion and exclusion criteria, 13 studies were selected for analysis. Post-renal transplantation, no significant discrepancy was noted among the groups based on the location of TCM viscera. However, when categorized according to TCM pathogenic factors, the groups with spleen and kidney yang deficiency, as well as liver and kidney yin deficiency, exhibited a statistically significant difference in the frequency.

CONCLUSION

Currently, the research on TCM syndromes pertaining to renal transplantation is in its nascent phase. It is imperative to conduct a multicentric, large-scale survey of TCM syndromes subsequent to renal transplantation in the ensuing years.

Key Words: Kidney transplantation; Syndrome; Literature analysis; Traditional Chinese medicine; Systematic review

Core Tip: At present, there are no reports on clinical research on the traditional Chinese medicine (TCM) syndromes and constitution of kidney transplant patients with multicenter and diverse approaches. This study searched for literature on TCM syndromes after kidney transplantation in China, conducted statistical analysis of the results, and sought to identify the underlying patterns.

INTRODUCTION

Although kidney transplantation remains the most efficacious modality for the management of renal failure; several challenges, such as graft rejection, immunosuppressant toxicity, and chronic allograft nephropathy, persist as unresolved postoperative issues. Concurrently, amidst ongoing enhancements in the pertinent post-transplantation renal technologies, several medical professionals within China have started investigating the applications of traditional Chinese medicine (TCM) in the post-transplantation renal context. This involves the assessment of TCM symptomatology and constitutional types, which are fundamental to the therapeutic management of diseases. Currently, clinical research reports on TCM syndromes and constitutions of patients undergoing kidney transplantation, involving multicenter collaboration and employing a variety of methodologies, are scarce. In the present study, we comprehensively reviewed the literature on TCM syndromes post-kidney transplantation within China, followed by a statistical analysis of the findings, with the objective of elucidating the intrinsic patterns.

MATERIALS AND METHODS

Inclusion criteria

Relevant reports on TCM syndromes post-kidney transplantation were retrieved from esteemed databases such as the China National Knowledge Infrastructure (CNKI), Wanfang Data Knowledge Service Platform, and Wipu Information. Next, we meticulously analyzed the statistical findings. This rigorous screening procedure was designed to identify and select the literature aligning with the specific research criteria pertaining to TCM syndrome categorization, clinical syndrome differentiation, and therapeutic modalities subsequent to kidney transplantation.

Exclusion criteria

(1) The basic content of the article is repetitive; (2) Articles with identical or partially identical data from the same author organization; (3) Articles published from different perspectives by the authors applying the same data; (4) Articles with serious data bias; (5) Articles not in line with the actual clinical situation; and (6) Articles without specific evidence of phenotyping.

Consultation strategy

In the initial phase, a fuzzy search algorithm was applied to comprehensively search the CNKI, Wanfang Data Knowledge Service Platform, and Wipu Information using the term “kidney transplantation“. The literature spanning from 1970 to 2021 was meticulously examined, yielding 109 articles through an “OR” Boolean search, including full texts containing the keywords “identification”, “evidence”, or “evidence type“ for a subsequent secondary search. Following this, we thoroughly analyzed whether the retrieved literature complied to the inclusion criteria. Subsequently, the inclusion and exclusion criteria were applied to comprehensively review the entire text. The literature and findings were meticulously examined, and expert consultations were sought, resulting in the identification of 13 articles that conformed to the specified criteria.

Statistical analysis

All enrolled documents were systematically categorized according to their TCM syndrome diagnosis and subsequently entered into an Excel spreadsheet for data compilation. The resulting data were meticulously analyzed utilizing t-tests and one-way analysis of variance (ANOVA) via Statistical Package for the Social Sciences 21.0 software, yielding statistically significant differences where P-values were found to be less than 0.05.

RESULTS

Our statistical data indicated that, out of a cohort of 2681 patients who underwent renal transplantation, in conformity with the prevalence of TCM symptomatology, the four predominant symptom categories, arranged in decreasing order of frequency, were spleen and kidney yang deficiency (constituting 27.27%), liver and kidney yin deficiency (comprising 20.32%), qi and yin deficiency (accounting for 18.87%), and spleen and kidney qi deficiency (representing 18.37%). These four categories were the most frequently observed, together constituting 84.83% of all recorded symptoms. The least common symptom was that of kidney-yin deficiency (Tables 1, 2, 3, 4 and 5).

Table 1 Statistical table of traditional Chinese medicine syndrome classification.

Group	Spleen and kidney qi deficiency	Spleen qi deficiency	Spleen kidney yang deficiency	Kidney qi deficiency	kidney yin deficiency	Qi-yin deficiency	kidney yang deficiency	Yin yang imbalance	Liver-kidney yin deficiency	Qi stagnation and blood stasis	Combined with dampness and heat
1	13	9	8	6	7	5	3	10	170	6	8
2	2	5	4	3	2	1	1	1	17	17	8
3	99	33	97	63	6	82	63	1	103	10	9
4	35	4	285	14		102			170
5	27	11	83	21		7			12
6	61	33	97	26		117			21
7	99		28			82			6
8	18		26			27			21
9	20		28			2			12
10	60		25			14
11	4		50			27
12	18					21
13	14					3
Mean	34.35	15.83	66.45	22.16	5	35.28	22.33	4	59.11	11	8.33
SD	32.80	13.54	79.87	21.81	2.64	41.42	35.23	5.19	69.33	5.56	0.57
Frequency	481	95	731	133	15	494	67	12	532	33	25

Table 2 Grouping according to the elements of traditional Chinese medicine visceral disease location.

Group	Kidney	Spleen and kidney	Other
1	Kidney qi deficiency	Spleen and kidney qi deficiency	Deficiency of both qi and yin
2	Kidney yin deficiency	Spleen-kidney yang deficiency	Qi stagnation and blood stasis
3	Kidney yang deficiency		Combined with dampness and heat
F value/t value	1.5 (F)	-1.236 (t)	0.8 (F)
P value	0.269	0.243	0.466

Table 3 Grouping by traditional Chinese medicine pathogenic factors.

Group	Yin deficiency	Yang deficiency	Deficiency of vital energy
1	Kidney yin deficiency	Spleen-kidney yang deficiency	Spleen-kidney qi deficiency
2	Liver-kidney yin deficiency	kidney-yang deficiency	Spleen qi deficiency
3			Kidney qi deficiency
4			stagnation of qi and blood
F value/t value	-2.541 (t)	-2.323 (t)	0.799 (F)
P value	0.031	0.045	0.507

Table 4 Single factor analysis of variance based on the location of traditional Chinese medicine visceral diseases.

Group	Square sum	DOF	MS	F value	Statistical significance
Interblock	16473.599	4	4118.400	1.790	0.141
Intragroup	154109.679	67	2300.144
Sum	170583.278	71

Table 5 A single factor analysis of variance based on the pathogenic factors of traditional Chinese medicine.

Group	Square sum	DOF	MS	F value	Statistical significance
Interblock	10291.829	3	3430.610	1.413	0.247
Intragroup	157860.808	65	2428.628
Sum	168152.638	68

DISCUSSION

In the 1970s, Chinese researchers initiated the integration of TCM into the realm of kidney transplantation. Numerous commendable advancements have been achieved in the clinical deployment of TCM subsequent to kidney transplantation procedures[1]. Nevertheless, at present, all investigations are being conducted within a solitary medical center, characterized by divergent criteria for syndrome differentiation and therapeutic efficacy assessment across several departments, compounded by a significant degree of subjectivity amongst the medical practitioners, consequently exerting a constrained impact on the outcomes of the research. We primarily investigated the symptoms of TCM following kidney transplantation to enhance the precision of diagnostic differentiation and therapeutic interventions via comprehensive summarization, thereby augmenting clinical efficacy. "Treatment predicated on syndrome differentiation" constitutes the core and quintessence of TCM[2,3]. It is crucial to select an optimal statistical methodology to mitigate subjective biases inherent in the statistical data processing. This is essential for deriving clinically pertinent TCM evidence from patient data and literature sources[4]. Diverse pathologies following renal transplantation lack specific nomenclature within the domain of TCM, necessitating their categorization based on the individual constitutional states of patients. Uremia, inherently, represents a deficiency of the viscerals, whereas the surgical intervention further traumatically affects the venous and collateral circulation, compromising the qi and blood, thereby adding complexity to the classification[5]. Subsequent to renal transplantation, several complications including graft rejection, immunosuppressive medication toxicity, and chronic allographic nephropathy, among others, present with congruent clinical manifestations. The therapeutic approach of TCMs, characterized by dialectical treatment, obviates the need for invasive methodologies such as renal biopsy involved in conventional Western medicine[6-8]. Consequently, the profound importance of investigating TCM syndromes post-kidney transplantation cannot be overstated, and it is imperative to collate and analyze the literature to facilitate taxonomic inquiry.

After a renal allograft transplantation, the graft initiates its functional activity, thereby augmenting urinary excretion, facilitating the elimination of metabolic by-products, rectifying acid–base discrepancies, and restoring homeostasis of electrolytes, and normalizing the renal function. However, these functions can only eliminate the evil qi and cannot support the righteousness. Damage to the righteousness directly affects the spleen and kidney function of transportation, causing spleen and kidney yang deficiency and reduced transportation[9].

This is also consistent with the results of our statistics. The defense of the recipient’s "positive qi" against the donor's "allogeneic kidney" after kidney transplantation is a manifestation of the confrontation between good and evil[10]. An equilibrium between the yin and yang energies within the internal organs is crucial. An analysis of our statistical findings revealed that the post-kidney transplantation categorization of TCM’s organ elements did not yield statistically significant differences when subjected to one-way ANOVA, irrespective of the patient cohort. Consequently, the negligible discrepancy between the categorization based on internal organ elements and disease locations, as well as the non-substantial differentiation amongst patient groups, could be attributed to the limited data available for such grouping criteria. Moreover, an analysis of the aggregation of pathogenic elements within the framework of TCM revealed a statistically significant disparity, with the liver and kidney yin deficiency cohort demonstrating a markedly higher prevalence of patients compared to the kidney yin deficiency cohort alone. Similarly, the spleen and kidney yang deficiency cohort exhibited a considerable increase in patient numbers in relation to the kidney yang deficiency cohort. This connotes that yin insufficiency is the primary etiology of liver-kidney yin insufficiency post-kidney transplantation, whereas yang insufficiency is the predominant cause of spleen–kidney yang insufficiency. Consequently, a therapeutic approach focusing on consolidating the constitutional integrity and eradicating exogenous pathogens subsequent to kidney transplantation is warranted. In the context of a unidirectional ANOVA, the statistical analysis revealed no significant disparities among the three groups. Although deficiency syndrome is the primary type after kidney transplantation, no difference existed in different subtypes.

The differential characteristics between Western medicine and TCM are marked by the latter’s non-reliance on instrumental measurement outcomes, and its nature is not one of absolute dichotomy. Within the domain of complexity science, the human body is perceived as a self-organizing, self-regulating, self-stabilizing, and self-adaptive open system embodying complexity[11,12]. It is imperative to acknowledge the multifaceted nature of outcomes to categorize the evidence in TCM. Within the realm of contemporary scientific inquiry, it is common to encounter intricate amalgamations of different constituent elements, mirroring the inherent complexity and variability inherent in the onset, progression, and transformation of diseases. Similarly, prospective investigations into the evidence base of Chinese medicine post-renal transplantation must be attuned to this level of sophistication.

CONCLUSION

We conducted a literature review of TCM syndromes after renal transplantation. The results obtained outlined their syndromic characteristics; however, due to the limitations of the sample size and the level of research, the research criteria of the selected literature varied, and the conclusions of the study are debatable. There exists a lack of dynamic observation and analysis indexes within a fixed time, making it difficult to meet the reality of Chinese medicine clinical diagnosis and treatment. The diagnostic and inclusion criteria of Chinese medicine symptoms after renal transplantation cannot be completely unified, and the gold standard of postoperative pathological typing has not been combined. Therefore, it is not possible to describe the Chinese medicine symptom typing following renal transplantation in an all-round manner. Large samples and multi-center clinical data are required to meet the clinical needs of Chinese medicine and to provide objective basis and reference value for the clinical diagnosis and treatment of Chinese medicine in renal transplantation.