Wei Meihua (韋美華), Zu Yajie (祖亞潔)

Gastroenterology Department, Army General Hospital 263 Clinic, Beijing 101149, China

ABSTRACT

OBJECTIVE: To explore the effects of Yigan Tiaozhi Decoction on serum nitric oxide (NO), endotoxin and retinol binding protein 4 (RBP4) in patients with nonalcoholic fatty liver disease (NAFLD), and to provide evidence for clinical treatment of such patients. METHODS: A total of 92 patients with NAFLD admitted to Army General Hospital 263 Clinic from March 2013 to March 2017 were selected, and all patients were divided into the control group (n = 46)and the observation group (n = 46) according to the random number table method. The patients in the control group were given conventional treatment, and the patients in the observation group were treated with Yigan Tiaozhi Decoction on the basis of the control group. Liver function, blood lipid levels, serum NO, endotoxin, RBP4 levels and clinical efficacy were observed and compared between the 2 groups before and after treatment. RESULTS: Before treatment,there was no significant difference in serum alanine aminotransferase, glutamyltranspeptidase, aspartate aminotransferase,total cholesterol and triglyceride levels between the 2 groups (P > 0.05); after treatment, the serum levels of alanine aminotransferase, glutamyltranspeptidase, aspartate aminotransferase, total cholesterol and triglyceride in the observation group were lower than those in the control group, and the difference was statistically significant (P < 0.05); before treatment, there was no significant difference in serum NO, endotoxin and RBP4 levels between the 2 groups (P > 0.05);after treatment, the serum NO, endotoxin and RBP4 levels in the observation group were lower than those in the control group, and the difference was statistically significant (P < 0.05); the total effective rate of treatment in the observation group (89.13%) was significantly higher than that in the control group (76.09%), and the difference was statistically significant (P < 0.05). CONCLUSION: Yigan Tiaozhi Decoction is effective in NAFLD, which can reduce serum NO,endotoxin and RBP4 levels, improve liver function and reduce blood lipid levels.

KEYWORDS: Yigan Tiaozhi Decoction; Nonalcoholic fatty liver disease; Serum NO; Endotoxin; Retinol binding protein 4

Nonalcoholic fatty liver disease (NAFLD) is a metabolic stress liver injury associated with genetic susceptibility and insulin resistance, including nonalcoholic steatohepatitis, simple fatty liver, and related cirrhosis.Serious cases will develop into liver cancer[1,2]. Most of these patients lack self-conscious symptoms, but some patients still have symptoms such as pain, fatigue,hepatosplenomegaly and indigestion in the liver area. Some patients also have symptoms of high fasting blood glucose,hypertension, dyslipidemia and visceral obesity[3,4]. In addition to causing liver cancer, decompensated cirrhosis and liver recurrence, NAFLD also has a great influence on the development of other chronic liver diseases, and it also plays a role in causing atherosclerosis and type 2 diabetes in patients, severely threatening patients' life and health and quality of life, and having become the focus of research in the field of contemporary medicine[5,6].

The treatment of liver-protecting drugs is commonly used in clinical practice, but it is not effective in improving liver function and blood lipid levels in patients. In recent years, traditional Chinese medicine(TCM) has been effective in the treatment of NAFLD,causing widespread concern. TCM believes that the main causes of NAFLD are greasy food, phlegm-turbidity stagnation, emotion disorder, and dysfunction of liver and spleen[7,8]. Therefore, this paper mainly studies the therapeutic effects of Yigan Tiaozhi Decoction on patients with NAFLD, and their serum inflammatory factors and liver function levels, which provides a reference for clinical effective treatment of such patients. It is reported as follows.

MATERIALS AND METHODS

General information

A total of 92 patients with NAFLD who were treated in Army General Hospital 263 Clinic from March 2013 to March 2017 were selected and divided into the control group and the observation group according to the random number table method, with 46 cases in each group.The control group consisted of 26 males and 20 females,aged 23-60 years old, with an average age of (45.27 ± 6.42)years old; duration of disease 2-9 years, average disease duration (4.20 ± 2.10) years; average body mass index(25.23 ± 2.45) kg/m2. There were 27 males and 19 females in the observation group, aged 25-62 years old, with an average age of (46.37 ± 5.25) years old; duration of disease 2-8 years, average disease duration (4.43 ± 2.01) years;average body mass index (26.34 ± 2.21) kg/m2. There were no significant differences in age, gender, disease duration and body mass index between the 2 groups, and there was no statistical significance (P > 0.05).

Inclusion criteria: all patients met the diagnostic criteria in the NAFLD Guidelines prescribed by the Chinese Medical Association[9], and were under 65 years old. Exclusion criteria: long-term drinking patients;lactating women; patients with severe infectious diseases;patients with severe heart, liver and kidney dysfunction;patients with severe mental illness and communication impairment. The ethics committee of the hospital had reviewed and agreed to conduct this study, and patients and their families had agreed to participate in the study.

Methods

Control group: patients were given oral ursodeoxycholic acid capsule (Sichuan Keruide Pharmaceutical Co., Ltd.) for twice a day, 250 mg per time. And they were given bicyclol tablets (Beijing Union Pharmaceutical Factory) orally for 3 times a day, 25 mg per time.

The observation group: on the basis of the same treatment of control group, the observation group was given Yigan Tiaozhi Decoction which was prescribed as follows: 20 g Radix Astragali seu Hedysari, 15 g Radix Curcumae, 20 g Rhizoma Alismatis, 15 g Rhizoma Acori Tatarinowii, 15 g Radix Salviae Miltiorrhizae, 15 g Camellia sinensis(L.)O.KuntzeThea sinensis L., 9 g Radix Bupleuri. There were addition and subtraction for different symptoms: for patients with liver qi stagnation, add 15 g Spica Prunellae and 15 g Fructus Aurantii; and for patients with spleen deficiency and dampness, add 15 g Radix Codonopsis, 15 g Poria cocos(Schw.)Wolf, 15 g Rhizoma Atractylodis Macrocephalae and 30 g Semen Coicis;and for patients with elevated transaminase, add 15 g Hypericum japonicum Thunb and 30 g Herba Sedi; for liver juice deficiency patients, add 15 g Herba Epimedii,15 g Radix Polygoni Multiflori and 15 g Fructus Lycii; for blood stasis patients, add 15 g Semen Persicae and 15 g Radix Paeoniae Rubra. The decoction was boiled with the boiling water, and patients took 150 mL in the morning and evening, with 4 weeks for a course of treatment, a total of 3 courses.

Observation indicators

Comparison of blood lipid levels and liver function before and after treatment in the 2 groups of patients

The main indicators included serum alanine aminotransferase, glutamyl transpeptidase, triglyceride,total cholesterol, and aspartate aminotransferase. The detection method was as follows: 5 mL of venous blood of patients was taken in the morning, centrifuged for 10 min, and stored it at –20℃ for use. The serum alanine aminotransferase and glutamyl transpeptidase were detected by CI8200 automatic biochemical analyzer (Abbott Laboratories, USA). And aspartate aminotransferase, total cholesterol and triglyceride were detected by an automatic biochemical analyzer PUZS-300(Beijing Prang Medical Devices Co., Ltd.).

Comparison of serum NO, endotoxin and RBP4 levels before and after treatment in the 2 groups

The detection method was as follows: serum NO,endotoxin, and RBP4 levels were measured by enzymelinked immunosorbent assay and its corresponding kit(Shanghai Senxiong Biological Co., Ltd.).

Comparison of the therapeutic effects between the 2 groups of patients

The evaluation criteria were as follows[10]: Cured:patients had no obvious clinical symptoms, liver function,blood lipid level and B-ultrasound were normal; markedly effective: the patient's vital signs improved significantly,the clinical symptom score decreased by more than 70%,and the blood lipid level decreased by more than 20%.The liver function test was normal or decreased by more than 40%; effective: the patient's vital signs improved slightly, the clinical symptom score decreased to 30%,the liver function test results decreased to 20%, the blood lipid level decreased to 20%; invalid: the patient's condition did not improve or even was aggravated. Total effective rate = (number of cured cases + number of markedly effective cases + number of effective cases) /total number of cases × 100%.

Statistical methods

Data processing was performed using SPSS 22.0 statistical software. The measurement data was expressed by, and the test was performed by t; the counting data was expressed as a percentage, and the test was performed by χ2test. The difference was statistically significant (P < 0.05).

RESULTS

Comparison of liver function and blood lipid levels before and after treatment in the 2 groups of patients

Before treatment, the serum alanine aminotransferase,glutamyltranspeptidase, aspartate aminotransferase,total cholesterol and triglyceride levels in the 2 groups were not significantly different, and not statistically significant (P > 0.05). After treatment, the serum alanine aminotransferase, glutamyltranspeptidase, aspartate aminotransferase, total cholesterol and triglyceride levels in the observation group were decreased more than those in the control group, and the difference was statistically significant (P < 0.05). See Table 1.

Serum NO, endotoxin and RBP4 levels before and after treatment in the 2 groups of patients

Before treatment, the levels of serum NO, endotoxin and RBP4 in the 2 groups were not statistically significant(P > 0.05). After treatment, the serum NO, endotoxin and RBP4 levels in the observation group were lower than those in the control group, which was statistically significant (P < 0.05). See Table 2.

Treatment efficacy of 2 groups of patients

The total effective rate of the observation group was significantly higher than that of the control group, and the difference was statistically significant (P < 0.05). See Table 3.

DISCUSSION

In recent years, the incidence of obesity and related metabolic syndrome has increased globally, and the incidence of NAFLD in Europe and the United States hasalso gradually increased. Among them, the incidence of NAFLD in general adults has reached 10%-30%. Nonalcoholic steatohepatitis accounts for 10%-25%, and its chance of developing to liver cirrhosis is greater[11,12]. As a common clinical gastroenterology disease, NAFLD has a complicated pathogenesis, and both TCM and Western medicine hold different opinions. Western medicine believes that the incidence of NAFLD is related to intrahepatic inflammatory response. There are more Gram-negative enterobacteriaceae in this type of patients,and the intestinal flora imbalance is more serious. In addition, NAFLD and the body's fatty acid metabolism disorder, insulin resistance, cytokine abnormalities and oxidative stress have a certain relationship; if patients are not treated in time, it will lead to aggravation of the disease, and even develop into cirrhosis or liver cancer, which poses a great threat to the life safety of patients[13,14].

Table 1. Comparison of liver function and blood lipid levels before and after treatment in the 2 groups

Table 1. Comparison of liver function and blood lipid levels before and after treatment in the 2 groups

Notes: ① P < 0.05 compared with the control group; ② P < 0.05 compared with before treatment

Group Time Triglyceride(mmol/L)Control group (n=46) Before treatment 93.3±12.8 87.1±16.9 121.5±25.7 5.3±1.1 2.8±0.8 After treatment 47.3±13.7② 64.5±14.2② 66.1±15.3② 4.8±0.7② 1.8±0.5②Observation group (n=46)Before treatment 90.6±13.1 85.5±17.1 116.8±22.3 5.4±0.8 2.7±0.5 After treatment 38.3±11.5①② 55.3±12.1①② 56.1±13.2①② 4.0±0.5①② 1.4±0.3①②Aspartate aminotransferase(U/L)Glutamyltranspeptidase(U/L)Serum alanine aminotransferase(U/L)Total cholesterol(mmol/L)

Table 2. Comparison of serum NO, endotoxin and RBP4 levels before and after treatment in both groups

Table 2. Comparison of serum NO, endotoxin and RBP4 levels before and after treatment in both groups

Note: ① P < 0.05 compared with the control group; ② P < 0.05 compared with before treatment

Group Time Serum NO (umol/L) Endotoxin (EU/L) RBP4 (mg/L)Control group (n=46) Before treatment 66.3±8.1 170.4±17.3 30.7±2.7 After treatment 58.4±6.0② 154.3±14.7② 28.0±2.1②Observation group (n=46) Before treatment 65.6±7.3 169.2±18.4 31.1±2.3 After treatment 51.0±5.8①② 143.2±13.6①② 23.4±1.7①②

Table 3. Comparison of therapeutic effects between the 2 groups of patients [n (%)]

In recent years, the role of TCM in the treatment of NAFLD has become more and more obvious, and has been recognized by many clinical professionals, and has achieved remarkable therapeutic effects. TCM believes that NAFLD is mainly caused by greasy food, dysfunction of liver and spleen, phlegm stagnation, and emotion disorders. Therefore, TCM treatment method is mainly to reduce lipid and promote blood circulation and invigorate the spleen and disperse the stagnated liver-energy[15,16].In the combination of Yigan Tiaozhi Decoction for the treatment of patients with NAFLD in the self-prepared prescription of this study, Radix Bupleuri, Fructus Aurantii can regulate qi-flowing for relieving pain, and disperse stagnated liver qi for relieving qi stagnation,which has a significant effects in the inhibition of liver cell damage and necrosis and degradation of lipids.Rhizoma Alismatis can reduce lipid, and promote diuresis and diffuse dampness; Radix Astragali seu Hedysari can induce diuresis for removing edema, and enrich the blood and benefit qi; Radix Curcumae can disperse stagnated qi for relieving qi stagnation, activate blood circulation to relieve pain, cool blood and clear away heart-fire; Radix Salviae Miltiorrhizae has effect of cooling blood and relieving pain, promoting blood circulation for regulating channels, and dispersing stasis to relieve pain. Camellia sinensis(L.)O.KuntzeThea sinensis L has obvious curative effect in inhibiting lipid synthesis, promoting blood circulation and removing blood stasis, and improving microcirculation. The combination of the herbs can not only relieve liver and descend phlegm-turbidity, but also significantly promote blood circulation and regulate qiflowing, eliminate dampness to remove phlegm, and remove blood stasis[17].

The results of this study showed: ①The therapeutic effect of the observation group was significantly better than that of the control group in this study, indicating that the effect of the treatment combined with Yigan Tiaozhi Decoction is better than that of the simple drug treatment.In Yigan Tiaozhi Decoction, Rhizoma Alismatis has alkane-type triterpenes, which has the effect of promoting diuresis and removing dampness, and lowering liquid, and the effect of Radix Astragali seu Hedysari on tonifying qi and dispersing essence is obvious. Radix Bupleuri has the functions of dispersing stagnated liver qi for relieving qi stagnation and protecting liver, and can restore glycogen and RNA levels in liver cells to normal levels. The original and ribonucleic acids are restored to normal levels. Radix Curcumae, Radix Salviae Miltiorrhizae and Camellia sinensis(L.)O.KuntzeThea sinensis L have the functions of promoting blood circulation to remove blood stasis, inhibiting lipids and improving microcirculation.The combination of the above herbs can achieve the effects of regulating qi-flowing and activating blood circulation, dispersing stagnated liver qi and descending phlegm-turbidity, and at the same time, it can remove blood stasis, harmonize liver and spleen, and remove dampness and phlegm[18]. ② After treatment, the serum alanine aminotransferase, glutamyltranspeptidase,aspartate aminotransferase, total cholesterol and triglyceride levels in the observation group were lower than those in the control group, suggesting that Yigan Tiaozhi Decoction has a significant effect in improving liver function and lowering blood lipids, which was consistent with related research[19]. ③ Serum NO is a neurotransmitter that stimulates the secretion of hormones by the vagus nerve. Excessive serum NO may cause intestinal vasodilation and increased permeability, leading to endotoxemia and damage to the liver; while RBP4 is a circulating lipid source factor secreted by liver tissue,and its level can reflect the extent of liver disease[20]. The results of this study showed that after treatment, the serum NO, endotoxin, and RBP4 levels in the observation group were lower than those in the control group, indicating that Yigan Tiaozhi Decoction could help the body maintain the balance of intestinal flora, regulate lipid metabolism, and could further inhibit liver inflammation, reduce endotoxin levels and reduce the risk of liver fat lesions.

In summary, Yigan Tiaozhi Decoction is effective for patients with NAFLD, and can reduce serum NO,endotoxin and RBP4 levels, and has the effect of improving liver function and regulating blood lipids, and can be widely used in clinical practice.