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EFFECTIVITY OF LUMBROKINASE IN REDUCING PROTEINURIA ON

PATIENTS WITH DIABETIC KIDNEY DISEASE

Jonny

Nephrology Division, Department of Internal Medicine,


RS Kepresidenan RSPAD Gatot Soebroto, Jakarta, Indonesia
Email: jonny_army@yahoo.com
Mobile number: +628156032558

ABSTRACT

Diabetes Mellitus (DM) is currently developing epidemically and diabetic kidney


disease is a major complications affecting one-third of patients with DM. Lumbrokinase is an
extract from a worm belonging to the class Lumbricus rubellus, containing bioactive
proteolytic enzymes, it is known as an alternative therapy in reducing proteinuria. This study
aims to provide an idea whether the administration of Lumbrokinase (Tromboles®) can
reduce proteinuria in patients with Diabetic Kidney Disease. The study design is a
prospective observational and experimental study in 6 type 2 Diabetes Mellitus patients with
Diabetic Kidney Disease characterized by proteinuria in RSPAD Gatoto Soebroto. Samples
are given Lumbrokinase (Tromboles®) 250mg with a dose of 3x2 capsules daily for 12
weeks. Study results shows no significant difference between laboratory parameters before
and after Lumbrokinase administration. However, proteinuria seems to improve, it is marked
with decreased UACR level after Lumbrokinase administration. Our study concluded that
lumbrokinase appears to be able to decrease proteinuria in type 2 DM patients with Diabetic
Kidney Disease. However, further research with more samples is needed.

Keywords: DM, Lumbrokinase, traditional medicine

Disclaimer: The views expressed in this article is individual and not an official position of the
institution or any other parties.

Funding: No external funding is involved

Abstract word counts: 172 words

Word counts: 1457 words

Conflict of interest: The authors reported no financial or personal conflict of interest


Background

Diabetes Mellitus (DM) is currently developing epidemically around the world due to
[1]
lifestyle changes . According to WHO (World Health Organization), the number of DM
patients increased from 108 million in 1980 to 422 million in 2014, and is expected to be 642
million by 2040.[2,3] Diabetic Nephropathy is one of the major complications affecting about
one-third of DM patients of either type one or two3 characterized by progressive renal mass
expansion due to accumulation of extracellular matrix (ECM) in the form of collagen IV,
laminin, fibronectin, proteoglycans, etc.{4,5] The concept of Diabetic Nephropathy is now
transformed into Diabetic Kidney Disease (DKD). The concept of Diabetic Nephropathy
emphasizes a clear definition and identification of kidney disease, while the concept of
Diabetic Kidney Disease emphasizes the complexity and heterogeneity of kidney disorders in
DM patients.[6]

The parameters used to assess Diabetic Kidney Disease are proteinuria, which
consists of macroalbuminuria and microalbuminuria.[7] Microalbuminuria showed an increase
in urine albumin excretion as much as 30-299 mg/g creatinine. While macroalbuminuria is
when it is excreted more than 300 mg/g creatinine. A more accurate examination for
assessing proteinuria today is with UACR (Urinary Albumine Creatinine Ratio).[8]

One of the alternative therapies for reducing proteinuria in Diabetic Kidney Disease is
by using Lumbrokinase, which includes Traditional Chinese Medicine. Lumbrokinase is an
extract from one type of a worm in class Lumbricus rubellus that contains bioactive
proteolytic enzymes. Studies show that Lumbrokinase has anti-inflammatory, antioxidant,
fibrinolytic, antimicrobial, and anticancer effects.[9-13] Lumbrokinase is a proteolytic enzyme
that acts as a plasminogen activator and serine protease-specific fibrin. The mechanism of
action is similar to tissue activator plasminogen (t-PA) which has thrombolytic activity when
there is fibrin. Lumbrokinase also divides fibrinogen and fibrin.[14]

Research on administration of Lumbrokinase in the field of nephrology is still limited.


In patients with diabetic kidney disease, Lumbrokinase administration is thought to increase
the degradation of extracellular matrix.[15] Fei et al study on primary nephrotic syndrome
patients showed that administration of Lumbrokinase for 12 weeks effectively decreased
clinical symptoms and proteinuria.[16] Similarly, Hou et al study on 12 patients with nephrotic
syndrome with hypercoagulation showed that administration of Lumbrokinase for 20 days
significantly decreased the protein in 24-hours-urine.[17]
This study aims to provide an idea whether the administration of Lumbrokinase
(Tromboles®) can reduce proteinuria in patients with Diabetic Kidney Disease by monitoring
the effectiveness towards these patients.

Materials and Methods

The study was conducted by prospective observational experimental in type 2


Diabetes Mellitus patients with Diabetic Kidney Disease characterized by proteinuria. The
sample of this research is the Chronic Kidney Disease patients in 4th stage or below
undergoing outpatient at the polyclinic of Kidney Hypertension RSPAD Gatot Soebroto from
January to September 2017. The number of samples is six people with age ranging between
39 to 76 years that consist of three men and three women. There are four patients with
hypertension, and all of them do not use ACEI (Angiotensin Converting Enzyme Inhibitor) or
ARB (Angiotensin Receptor Blocker).

Patients are given Lumbrokinase (Tromboles®) 250mg with a dose of 3x2 capsules
daily for 12 weeks. Before Lumbrokinase was given, laboratory parameters such as
proteinuria (UACR), serum fibrinogen level, serum urea, and serum creatinine were
examined. The estimated glomerular filtration rate was calculated based on the serum
creatinine level with the modified diet renal disease (MDRD) equation. Laboratory
parameters are checked again every 4 weeks (monthly) consecutively for 12 weeks.

Results

After Lumbrokinase was given for 12 weeks, results obtained are shown in table 1.

Table 1. Research results


Parameter Means SD p
UACR Pre- 813.33 528.615 .075
Post- 447.17 317.963
Fibrinogen Pre- 326.50 53.024 .750
Post- 302.83 43.157
Urea serum Pre- 43.83 14.892 .892
Post- 44.17 16.154
Creatinine Pre- 1.6667 .95847 .671
Post- 1.60 1.01587
eLFG Pre- 51.0 29.114 .674
Post- 53.0 27.914
From the results of the study there was no significant difference between laboratory
parameters before and after Lumbrokinase administration. However, proteinuria appears to
improve marked with decreased UACR level after Lumbrokinase administration (Figure 1).

Figure 1. UACR level before and after Lumbrokinase administration

Likewise, fibrinogen serum level generally appear to decrease after Lumbrokinase


administration (Figure 2).

Figure 2. Fibrinogen serum level before and after Lumbrokinase administration

While the other parameters did not appear to differ significantly between before and
after Lumbrokinase administration, although the mean urea serum, creatinine, and eLFG
level is decreasing.
Discussion

Lumbrokinase is an enzyme derived from the extraction of earthworm Lumbricus


rubellus. This enzyme consists of 6 isoenzyme proteases (LrPI-0, LrPI-1, LrP-I-2, LrP-II,
Lrp-III-1, dan LrP-III-2) with the molecular weight were about 20.000 Dalton, displayed a
broad pH range, and thermostable.[18] Lumbrokinase is fibrinolytic and antithrombotic that
reduces blood viscosity and thrombocyte aggregations. Other studies have shown
Lumbrokinase also has function as anti-inflammatory, anti-ischemic, and antifibrotic.[10-12,19]

Lumbrokinase is widely used as antithrombotic to treat ischemic stroke – cerebral


infract, coronary heart disease, diabetes mellitus, and deep venous thrombosis.[9,20] Countries
that have been used Lumbrokiase are China, Japan, Korea, Canada, and America.[18,21]
DLBS1033 is a bioactive protein fraction containing Lumbrokinase derived through
extraction technology. Biological half life of DLBS1033 was reported to be 70 minutes in
rats, which is estimated to be 4,9 hours in humans.[22,23]

The main function of Lumbrokinase is fibrinolytic due to its enzymes contain


aspargine or aspartic acid, and only a little proline or lysine.[18] Lumbrokinase as an
endogenous plasminogen activator, converting plasminogen to plasmin. Additionally, this
enzyme also can hydrolyze fibrin or fibrinogen directly into fibrin/fibrinogen degradation
product (FDP) and decrease plasminogen activator inhibitor (PAI). Lumbrokinase makes
hydrolysis of the filaments and controls the aggregation of red blood cells, thereby preventing
thrombus formation and accelerating blocked blood vessels.[18,20,24]

Figure 3. Lumbrokinase mechanism of action24

Besides two function mentioned above, Lumbrokinase is also known has function as
anti-ischemic. Animal experimental test indicate that this anti-ischemic is due to anti-platelet
activity because it increases cAMP and calcium release from calcium stores in cells;
antithrombotic activity due to resistance to intercellular adhesion molecule-1 expression
(ICAM-1); and anti-apoptotic effect due to the activation of janus kinase-1/signal transducers
and activators of transcription-1 (JAK1/STAT1).[25] Jin et al study on 51 patients with
cerebral infarction given Lumbrokinase 3x400mg for 28 days showed the lengthening of
kaolin partial thromplastin time (KPTT), increased t-PA, decreased D-dimer level, and
decreased fibrinogen level.[26]

Zijuan study conducted in Beijing showed that Lumbrokinase effectively decreased


ischemic stroke. In this study, fibrinogen serum and blood viscosity decreased significantly
after Lumbrokinase administration.[27] Kim et al study showed that administering earthworm
powder orally for 8 days with doses of 0,5 – 1g/kg body weight/day in rats with arteriovenous
fistula was useful in prevent and/or overcome thrombosis.[28]

In our study, there was a decrease in fibrinogen serum level although not statistically
significant. This is consistent with Fei et al study on 20 patients with nephrotic syndrome that
showed administration of Lumbrokinase 230mg with dose 3x2 capsules for 4 weeks
significantly decreased fibrinogen serum level (p <0,001).[16] Similarly in Chung et al study,
study on 50 patients with cerebral infarction after 3 weeks of attack showed that 3x2 capsules
Lumbrokinase for 4 weeks decreased fibrinogen serum level significantly (p <0,001).[29]
Fibrinogen serum level also decreased significantly (p <0,001) in Shu and Minghua study on
31 patients with Retinal Vein Obstruction (RVO) with Lumbrokinase dose 3x460mg for 3
months.[30] Xin et al’s study on 20 patients with unstable angina showed fibrinogen serum
level decreased with Lumbrokinase dose 3x2 capsules for 10-14 days.[31]

Fibrinogen serum level in our study also appeared to decrease after administration of
Lumbrokinase 230mg with dose 3x2 capsules for 12 weeks, but not significantly. The
seemingly “neutral” effect on fibrinogen level seen in this study might be confounded by
several factors and can disrupt the results. Previous studies have shown that the fibrinogen
synthesis is influenced by several conditions such as high protein intake, long smokers,
progesterone effects during luteal phase in women.[32] Limitations in this study are small
samples and do not measure the fibrin/fibrinogen degradation products (FDPs) which can
assess more definite fibrinogenolytic activity.

On diabetic nephropathy, a decrease of extracellular matrix (ECM) degradations of


glomerular will decrease glomerular proteolytic activity which causing increases
progressivity of glomerulosclerosis.[33,34] Lumbrokinase has a plasminogen activator (e-PA)
which plays an important role in ECM protease system. The plasminogen activator in
Lumbrokinase is similar to t-PA and urokinase (UK).[35] Lumbrokinase cleaves plasminogen
at four hydrolytic sites: Lys88-Arg78, Arg342-Met343m, Ala444-Ala445, and Arg557-
Ile558.[20] Besides that, on nephropathy diabetic, Lumbrokinase may attenuate the
progression of glomerulosclerosis and tubulointerstitial fibrosis by activating the
PA/plasmin/MMPs cascade. That cascade is initiated by single chain tPA (sc-tPA).[15,36] The
plasmin converts sc-tPA and sc-uPA to two chain tPA (tc-tPA) and tc-uPA, making them
more active in the conversion actions of plasminogen to plasmin.[36-38] Plasmin can degrade
the non-collagenous components of the ECM, whereas tc-uPA activates latent
metalloproteinase (MMP) and degrades type IV collagen.[36]

Reduction of MMP2 and MMP9 can suppress ECM degradation and accelerate the
progression of diabetic nephropathy. Lumbrokinase can up-regulate MMP2 and MMP9
thereby reducing type 4 collagen deposition that will reduce proteinuria and suppress the
progressivity of diabetic nephropathy.[15] Fei et al study showed a significant decrease in
proteinuria (p <0,01) after Lumbrokinase administration.[16] Reduced proteinuria was also
observed in Hu Hai and Jia Ru study after administration of Lumbrokinase orally for 20 days,
although the reduction was not significant (p > 0,05).[17] In our study, there was no
statistically significant decrease of proteinuria (p = 0,075) which marked by decreased
UACR. The UACR level was seen to decrease from 813,33mg/g to 447,17 mg/g after 12
weeks Lumbrokinase administration (Table 1).

In a study conducted by Ge et al in 2010, the increase of urinary albumin excretion


(UAE) may statistically significant suppressed (p <0,001) with administration of
Lumbrokinase 600.000 U/kg body weight/day or earthworm decoction 3g/kg body
weight/day intragastrically for 12 weeks. Administration of Lumbrokinase or earthworm
decoction has also shown a statistically significant decrease of immunolocalization type 4
collagen (p < 0,05).[39] Similarly in Sun et al study, administration of Lumbrokinase 600.000
U/kg body weight/day for 12 weeks revealed excellent results in reducing proteinuria.[15]
Decreased proteinuria seen with decreased amount of 24 hours UAE.[9] Sun et al divided the
group that received Lumbrokinase and group that received ACEi. Decreased UAE level were
6,14 in Lumbokinase group, whereas in the ACEi group was . These results differed
statistically significant (p <0,05).[15]
According to Tjandrawinata study, urea serum and creatinine level decreased after 14
days of DLBS 1033 administration.[32] Fei et all study found a decreased of creatinine serum
significantly (p <0,01).[16] The decrease in creatinine serum levels, although not significant,
was also found in Hu Hai and Jia Ru study on 12 patients with nephrotic syndrome with
Lumbrokinase 3x460mg orally for 20 days.[17] In our study, there was no decrease in urea
serum level, but the creatinine serum level decreased, although not statistically significant.

Tjandrawinata study on the use of Lumbrokinase in 20 healthy subjects showed that


Lumbrokinase was safe to use. The study assessed the mean of blood chemistry (liver
function, renal function, lipid profie, and fasting blood sugar) for 14 days of Lumbrokinase
administration and obtained results within the normal range of values. May be stated that
Lumbrokinase is safe to use, although the results are not significant (p >0,05).[32]

Conclusion

Lumbrokinase appears to be able to decrease proteinuria in type 2 DM patients with


Diabetic Kidney Disease. However, further research with more samples is needed.
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