Study design and recruitment
This is a randomised, double-blinded, placebo-controlled, multi-centre trial to evaluate the efficacy and safety of XZSJ granules in the treatment of patients with DKD Stage IV as well as qi deficiency and blood stasis syndrome. The protocol is guided by the Declaration of Helsinki, Good Clinical Practice (GCP) guidelines and the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT, 2013), see Additional file 1.
Before the implementation of the clinical trial, we obtained the written consent of the Ethics Committee. All subjects will be required to read carefully and sign the informed consent form before participating in this trial. The investigators should give the subjects sufficient time to understand the details of the clinical trial and answer as much as possible any questions related to the clinical trial in detail. Investigators will conduct the first screening for recruited subjects 7±3 days before baseline. The content of the first follow-up visit mainly includes the general information of the subjects, reviewing the diagnosis, inclusion and exclusion criteria, the efficacy and safety observation. Subjects that fulfil the inclusion and exclusion criteria will be given standardised western conventional treatment for 7 days before the second screening. Eligible subjects will then be randomised in a 1:1 ratio to receive either XZSJ granules or placebo. After randomization, all participants will be evaluated at baseline as well as weeks 4, 8 and 12.
Seventy-two subjects will be recruited from 6 hospitals in China, namely Shandong Provincial Hospital of Traditional Chinese Medicine, Shanxi Provincial Hospital of Traditional Chinese Medicine, Hebei Provincial Hospital of Traditional Chinese Medicine, The First Affiliated Hospital of Beijing University of Chinese Medicine Dongzhimen Hospital, The First Affiliated Hospital of Tianjin University of Chinese Medicine, and The First Affiliated Hospital of Henan University of Chinese Medicine (Table 1). Recruitment will be directed at patients with DKD and conducted by clinical staff at outpatient clinics or through recruitment brochures on hospital notice boards and WeChat application programmes.
Diagnostic criteria
We will recruit participants aged between 25 and 75 years, who meet the diagnostic criteria for DKD based on the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guidelines [22], the Kidney Disease Improving Global Outcomes (KDIGO) 2012 Clinical Practice Guideline [23] and Chinese Diabetes Association Chinese Diabetic Kidney Disease Prevention and Treatment Clinical Guidelines [24]. For a diagnosis of DKD, patients with DM should have at least one of the following conditions: 1) Albuminuria (for microalbuminuria, out of three tests, two repeated tests performed within 3–6 months will need to produce abnormal results); 2) Diabetic retinopathy with CKD; 3) DKD confirmed by renal biopsy. If any of the following occurs, the chronic kidney disease is considered to be caused by other reasons and needs to be ruled out: 1) Shorter course (type 1 diabetes <10 years) or no diabetic retinopathy; 2) Estimated glomerular filtration rate decreased rapidly; 3) Urine protein increased rapidly or nephrotic syndrome appeared; 4) Refractory hypertension; 5) Active urine sediment (red blood cells, white blood cells or cell casts, etc.); 6) Complicated with symptoms or signs of other systemic diseases; 7) After treatment with ACEI or ARB, the eGFR decreased by more than 30% within 3 months; 8) Kidney ultrasound found abnormal.
After diagnosis of DKD, we will refer to the stage differentiation of diabetic nephropathy proposed by Danish scholar Mogensen, Combined with the stage differentiation of CKD by recommendations of the KDIGO guideline: the CKD staging (G1 stage: eGFR≥90 mL/min/1.73m2, G2 stage: 90>eGFR≥60 mL/min / 1.73m2, G3 stage: 60>eGFR≥30 mL/min / 1.73m2, G4 stage: 30>eGFR≥15 mL/min / 1.73m2, G5 stage: eGFR<15 mL/min / 1.73m2) ; The albuminuria staging (A1 stage: Urinary albumin-to-creatinine ratio (UACR) <30 mg/g, A2 stage: UACR 30～300 mg/g, A3 stage: UACR>300 mg/g), to determine the staging criteria of DKD: 1) DKD stage I: High filtration rate stage, UACR<30 mg/g, eGFR is much greater than 90 mL/min/1.73m2; 2) DKD stage II: Normal proteinuria stage, UACR<30 mg/g, eGFR≥90 mL/min / 1.73m2; 3) DKD stage Ⅲ: Microalbuminuria stage, UACR: 30～300 mg/g, eGFR≥90 mL/min / 1.73m2; 4) DKD stage Ⅳ: Clinical proteinuria stage, UACR> 300 mg/g, eGFR≥30 mL/min/1.73m2; 5) DKD stage V: End-stage renal failure, eGFR<30 mL/min/1.73m2. Patients with DKD consistent with Mogensen Stage IV (UACR>300mg/g, eGFR≥30 mL/min/1.73m2), will be considered in this trial.
Patients should also meet the diagnostic criteria for qi deficiency and blood stasis syndromes, which were adapted from the TCM Clinical Diagnosis and Treatment Plan for 95 Diseases in 22 Specialties, issued by the State Administration of Traditional Chinese Medicine of China. Patients should present with at least 3 of the following signs and symptoms for a diagnosis of qi deficiency to be established: 1) fatigue, 2) exhaustion after talking, 3) prone to sweating, 4) swollen tongue with teeth marks, 5) weak pulse. Patients should present with at least 2 of the following signs and symptoms for a diagnosis of blood stasis syndrome to be established: 1) sharp pain in a fixed location which worsens at night, 2) numbness or hemiplegia, 3) dry, scaly skin, 4) petechiae, purplish lips and tongue, dark spots on the tongue, or prominent sublingual vessel. TCM syndrome diagnosis will be conducted independently by 2 TCM physicians with experience in nephrology. The patient will be recruited if both physicians have similar diagnosis. A third physician will be consulted should there be differing diagnoses.
Inclusion/Exclusion criteria
Inclusion criteria
Patients should have DKD consistent with Mogensen Stage IV, age between 25 and 75 years, eGFR of 30-89mL/min/1.73m2 without dialysis, 24-hour urinary protein (24h-UP) <3g, blood pressure ≤ 160/90mmHg and hemoglobin A1c (HbA1c) levels ≤ 9%.
Exclusion criteria
We will exclude patients who have had severe infection, anemia, electrolyte imbalance, or acute complications of DM in the past 4 weeks; severe cardiac, cerebral, hepatic, or hemorrhagic diseases (e.g. cerebral infarction, cerebral hemorrhage, transient ischemic attack, myocardial infarction, unstable angina, heart failure, hepatic inadequacy with aspartate transaminase (AST) or alanine aminotransferase (ALT) levels more than twice the normal upper limit) in the past 3 months; consumed corticosteroids or immunosuppressants in the past 3 months; or had renal transplantation. We will also exclude patients with oliguria, anuria, severe edema, massive pleural or peritoneal effusion, active hepatitis B, mental disorders, female patients who are pregnant or breastfeeding, as well as patients with an allergy to the trial drug or who are currently participating in other clinical studies.
Handling of withdrawal and dropout
Participants will be allowed to withdraw from the trial at any time. Reason and date of withdrawal will be recorded in the CRF. Investigators will withdraw participants from the trial, should participants have an occurrence of diseases or conditions mentioned in the exclusion criteria, severe complications and/or general health deterioration, serious adverse events, rapidly increasing levels of serum creatinine (more than 50% of baseline) or ESRD, violate the trial protocol, or loss to follow-up to ensure the safety and quality of the trial.
Randomisation and blinding
Eligible participants will be allocated to either intervention or control group in a 1:1 ratio. Participants will be referred to an administrator, who is not involved in recruitment and follow-up of participants. The administrator will have the randomisation sequence numbers, which will be pre-generated by Beijing University of Chinese Medicine Centre for Evidence-based medicine using Statistical Analysis System (SAS version 9.2). Sequence numbers will be kept in sealed, opaque envelopes, which will be opened sequentially and revealed to participants on the day of randomisation. Participants, investigators and statisticians will be blinded to allocation to ensure allocation concealment.
Intervention
Eligible patients will be administered with routine treatment for DKD as per recommendations by KDIGO 2012 Clinical Practice Guideline [23] and Chinese Diabetes Association 2019 Chinese Diabetic Kidney Disease Prevention and Treatment Clinical Guidelines [24]. These include regulation of blood glucose to maintain HbA1c levels £ 9% and regulation of blood pressure at £ 140/90 mmHg, except for individuals aged 60 years or older, for whom the threshold for systolic blood pressure will be £ 160mmHg. Patients assigned to the intervention and control arm will receive XZSJ granules and placebo respectively. Patients will be required to consume one pack twice daily for 12 weeks, and will be advised against using other modes of TCM treatment during this period. XZSJ granules consists of astmgali radix, eucommiae cortex, sargassum, eupolyphaga, radix rhei et rhizome, and smilacis glabrae rhixoma (Table 2), while placebo granules are made from dextrin. Both types of granules will be provided by Beijing Tcmages Pharmaceutical Co. Ltd. (Beijing, China) and will have similar packaging, colour and taste to prevent potential unblinding. Designated drug distributors will distribute either XZSJ granules or placebo to participants at each visit and record the serial number, number of bags taken as well as number of bags returned for accountability.
Data collection and follow-up plan
The standardized CRF designed for this study will be used to collect data at each scheduled visit, which will be kept in a locked cabinet. The subject information is illegal or unauthorized given to access, disclosure and dissemination. Clinical trial data will be reasonably recorded, processed, and maintained to ensure confidentiality of records and subject information. Subjects will be evaluated during the enrolment (-1week), baseline (0week), and double-blind treatment period (4, 8 and 12 weeks). Each follow-up visit should take place within ±3 days of the scheduled time. The screening visit will collect background information during the screening period, including demographic indicators and general clinical data. Demographic indicators include date of birth, nationality, sex, height and weight. General clinical data include previous medical history, treatment history, and information related to the diagnosis of the disease (including UACR, Scr, eGFR, etc.), vital signs and physical examination, concomitant disease, and combined medication. From the second follow-up visit to the end of the trial, each follow-up collecting information will include the relevant data of TCM syndromes, vital signs, physical examination and relevant laboratory examination results in the trial. Hemoglobin A1c (HbA1c) and quality of life scales will be measured and collected during the screening period and 12 weeks. The follow-up visit schedule of data collection is shown in Figure1 and Figure 2. In this trial, we will adopt the form of paper/electronic data double entry. All CRF data will be imported into the electronic data management system EpiData 3.1, which is password protected to ensure confidentiality of information. Two investigators will independently enter the data and any discrepancies will be resolved to ensure accuracy. Problems found during the data entry process will be reported to the monitor, who would raise a query to the investigator. All queries will be documented and kept for future reference.
Primary and secondary outcomes
Primary outcome measures of the clinical trial include UACR, Scr and eGFR. These results will be measured at baseline as well as weeks 4, 8 and 12 after randomization. Secondary outcome measures include hemoglobin (Hb), albumin (Alb), Kidney Disease Quality of Life-Short Form (KDQOL-SF) [25], EuroQol Five Dimensions questionnaire (EQ-5D) [26] and the TCM syndrome score, which will be recorded at baseline as well as weeks 4, 8 and 12. EQ-5D consists of the EQ-5D health description system which assesses mobility, self-care, usual activities, pain/discomfort and anxiety/depression, as well as the EQ-VAS, which assesses quality of health, with higher scores indicating better health. KDQOL-SF scale consists of the short form health survey (SF-36) and kidney disease-targeted scales (KDTA). SF-36 assesses for physiological function, physical pain, general health, mental health, emotional function, social function, energy and health changes. KDTA assesses for symptoms, effects and burden of kidney disease, work status, cognitive function, social quality, sexual function, sleep and social support. Higher scores on KDQOL-SF and EQ-5D indicate better health status. TCM syndromes are graded based on the severity of symptoms related to qi deficiency and blood stasis, with higher scores reflecting more severe symptoms. Changes in syndrome scores will be assessed to be significant (reduction in score by ³70%), effective (reduction in score by ³30%) or invalid (reduction in score by <30%).
All laboratory indicators including UACR, Scr, Hb and Alb will be tested by Dongzhimen Hospital. eGFR will be calculated using the CKD-EPI formula. Differences in primary and secondary outcomes will be calculated and used for analysis to reduce biasedness caused by differences in baseline data. (change rate = change value / baseline detection, change value = baseline detection value-detection value at the Nth week of medication).
Safety
For this study, an adverse event (AE) is any unfavorable sign (including abnormal laboratory finding), symptom or disease which might or might not have a causal relationship with the intervention. Events related to physiological changes (e.g. menopause, menstrual cramps) will not be considered as an AE. Serious adverse event (SAE) is any untoward medical occurrence that leads to death, is life-threatening, a congenital defect, causes permanent or severe disability/incapacity or requires hospitalisation or prolongation of hospitalisation. In the event of an AE, the time of onset, duration, severity, intervention measures and outcome will be recorded in the CRF. Patients will be followed-up for their AE till resolution. In the event of a SAE, the SAE form will be documented and submitted to the research unit, ethics committee and project unit of Dongzhimen Hospital within 24 hours. Appropriate treatment for any SAEs will be administered for participants and the trial will be suspended till further notice.
Adverse drug reaction (ADR) refers to any harmful or undesired effects caused by the trial drug at any dose, such as exacerbation of existing illnesses and injuries or untoward events caused by overdose, abuse, withdrawal, allergy and toxicity. If there is even one reasonable possibility of a causal relationship between trial drugs and ADRs, the association cannot be ruled out. All ADRs will be recorded even if there is only one reasonable possibility of a causal relationship. Patients will be followed-up for their ADRs till resolution.
Sample size justification
As this is the first study to explore the efficacy of XZSJ granules on patients with DKD, we plan to recruit 60 subjects for both arms for a preliminary analysis. Allowing for a dropout rate of 20%, a total of 72 subjects will be needed, with 12 subjects being recruited from each centre. We hope that results of this trial will provide data support for the calculation of sample sizes for future large-scale clinical trials involving patients with DKD.
Quality control
Prior to trial commencement, all investigators will receive training in Good Clinical Practice (GCP) and Standard Operation Procedures (SOPs) constructed for this trial to ensure quality of study procedures. Principal investigators as well as the supervisory and administrative departments of the pharmaceutical company will oversee implementation of the trial. All centres will be actively involved in quality control during data processing. The study team will conduct interim monitoring of trial implementation, data quality and integrity of the data to ensure that all processes comply with GCP and SOPs.
Statistical analysis
Statistical analysis will be conducted using Social Science Statistical Software Package (SPSS) Version 22.0 by a statistician who is blinded to treatment allocation. Continuous variables will be expressed as mean ± standard deviation (SD), while categorical variables will be expressed as n(%). t-test or t’-test will be used for the analysis of continuous variables with a normal distribution, based on results of homogeneity of variance. Mann-Whitney-Wilcoxon test will be used for the analysis of continuous variables without a normally distribution. Statistical analysis will assume a two-sided test and 95% confidence interval. P <0.05 will be considered statistically significant.
Ethics and dissemination
This trial has been registered at Chinese Clinical Trial Registry http://www.chictr.org.cn/. The study will be conducted in compliance with the Declaration of Helsinki and GCP guidelines. Data of this trial will be uploaded into ResMan at http://www.medresman.org/ and posted on Chinese Clinical Trial Registry. Results of this trial will be disseminated to the public through academic conferences and peer-reviewed journals.