Tripterygium wilfordii Hook F (a traditional Chinese medicine) for primary nephrotic syndrome.
BACKGROUND
Tripterygium wilfordii Hook F (TwHF), a traditional Chinese herbal medicine used as an immunosuppressive agent, has been prescribed in China for patients with primary nephrotic syndrome (NS) for more than two decades. Although patients with primary NS in China have benefited from TwHF treatment, its properties have not yet been fully understood.


OBJECTIVE
To assess the benefits and harms of TwHF for patients with primary NS.


METHODS
We searched the Cochrane Renal Group's specialised register (August 2012), Cochrane Register of Controlled Trials (CENTRAL, The Cochrane Library 2012, Issue 8), EMBASE (1966 to August 2012), and MEDLINE (1966 to August 2012). We also searched CBM (Chinese Biological Medical Database) (1978 to November 2010), CNKI (Chinese National Knowledge Infrastructure) (1979 to November 2010), VIP (ChongQing WeiPu Chinese Science and Technology Periodical Database) (1989 to November 2010), WanFang Database (1980 to November 2010), and reference lists of articles (6 November 2010).


METHODS
Only randomised controlled trials (RCTs) were included. Two standardised preparations of TwHF were investigated: ethanol-ethyl acetate extract and chloroform-methanol extract. All other TwHF preparations were excluded because of reported toxicities. Other traditional Chinese herbal medicines were also excluded. All included RCTs had a follow-up of at least three months.


METHODS
Data extraction and risk of bias assessment were undertaken independently by two authors. Where details of randomised sequence generation and allocation concealment were absent or inadequately reported, we contacted original study investigators for verification and details of the procedure. For dichotomous outcomes (remission and drug-related adverse events) we used risk ratio (RR) with 95% confidence intervals (95% CI) and mean difference (MD) for continuous outcomes (urinary protein excretion, serum albumin and serum creatinine).


RESULTS
Ten studies enrolling 630 participants were included. Overall, the quality of evidence was suboptimal due to the small number of included studies enrolling small numbers of participants; short follow-up in each study; only a few studies in each comparison category; and major concerns with methodological bias. Four studies (293 participants) contributed to the comparison of TwHF versus non-TwHF. TwHF significantly increased complete remission (RR 1.46, 95% CI 1.18 to 1.80) and complete or partial remission (RR 1.26, 95% CI 1.10 to 1.44) without escalating the adverse events profile at the last follow-up (12 to 16 months). Four studies (223 participants) compared TwHF with prednisone. There were no statistically significant differences between complete remission, partial remission, and complete or partial remission. Two studies (114 participants) contributed to the comparison of TwHF versus cyclophosphamide (CPA) at the last follow-up (3 to 12 months). There were no statistically significant differences between complete, partial, or complete or partial remission. One study (46 participants) reported TwHF was associated with a significantly lower serum creatinine compared with CPA (MD -14.00 μmol/L, 95% CI -26.43 to -1.57). No serious adverse events of TwHF were observed. One study (37 participants) reported TwHF was associated with a significantly lower risk of psychosis when compared to prednisone (RR 0.11, 95% CI 0.01 to 0.75), and two studies showed a significantly lower risk of hair loss with TwHF when compared to CPA ((2 studies, 114 participants): RR 0.11, 95% CI 0.02 to 0.59).


CONCLUSIONS
TwHF may have an add-on effect on remission in patients with primary NS. There was insufficient evidence to assess if TwHF was as effective as prednisone or CPA. More methodologically sound and sufficiently powered studies, with adequate follow-up would help to better inform management options for the use of TwHF for primary NS. TwHF should be further directly compared with other widely used immunosuppressive agents after the superiority over placebo or no treatment has been clearly established.
Division of Nephrology, State Key Discipline and State Key Laboratory of Kidney Diseases (2011DAV00088), Chinese People's Liberation Army (PLA) General Hospital (301 Hospital), Chinese PLA Medical Academy, Fuxing Road 28, Haidian District, Beijing, China, 100853.
Yizhi
Y
Chen
Zhixiang
Z
Gong
Xiangmei
X
Chen
Li
L
Tang
Xuezhi
X
Zhao
Qing
Q
Yuan
Guangyan
G
Cai
D003520:Cyclophosphamide / Q000627:therapeutic use; D004365:Drugs, Chinese Herbal / Q000009:adverse effects / Q000627:therapeutic use*; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects / Q000627:therapeutic use*; D009404:Nephrotic Syndrome / Q000188:drug therapy*; D008517:Phytotherapy / Q000379:methods*; D011241:Prednisone / Q000009:adverse effects / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic; D012074:Remission Induction / Q000379:methods; D029757:Tripterygium / Q000009:adverse effects
D004365:Drugs, Chinese Herbal; D007166:Immunosuppressive Agents; D003520:Cyclophosphamide; D011241:Prednisone