aloe gel asmiha

8/12/2019 Aloe Gel Asmiha

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EFFECT OF ALOE GEL IN ENHANCING

DIABETIC WOUND HEALING

Djanggan Sargowo, Yudha Handaya,

Askandar Tjokroprawiro

Brawijaya Medical School

Malang1


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DM

2003 (197 millions)2010 ( 50%)

2025 (333 millions/6,3% population)

77% Developed Country

(Lauderdale 2006, Goycheva,et al 2006)

WHOIndonesia : 4th largest population with DM

2000(5,6 millions)2006(14 millions); 2025 (6,5% ofpopulation)

(sidartawan 2007)

2010 ( 7 jt) no 92030 (12jt)No 6 (IDF)

(Tjokropawiro 2010)

DM (15% DFU)

amputation( 84% DFU)

Surabaya3,8% Fountain IVDFU(Beem et al 2007,Tjokropawiro 2011)

BACKGROUNDS

2


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3

Grade 0pre-ulcerative lesion, healed

ulcers, presence of bony

deformity

Grade 1superficial ulcer withoutsubcutaneous tissue

involvement

Grade 2penetration through the

subcutaneous tissue (may

expose bone, tendon, ligamentor joint capsule)

Grade 3osteitis, abscess, or

osteomyelitis

Grade 4gangrene on the forefoot

Grade 5 gangrene on the entire foot

WAGNER CLASSIFICATION


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# Micro/Macroangiopaty

diabetic foot ulcers

Wound Healing

Wound healing complexmediated by :

vascular, neuronal, cellular & immunefactors,

Wound healing on DM

grow th factor &pro-angiogenic cytokinesmatrix deposition & remodel l ing(Brownlee2005,Ralf et al 2005)

AngiopathyNeuropathy

combination(David et al 2002)

Imbalance Wound Healing Phases

4

WOUND HEALING DISORDERS


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DMHyperglycemia ROS apoptosis angiogenesis dysfunction (#tube formation)WH diabetic foot ulcers (DFU) progression amputation

(David et al2002,Hesham et al2006 ,Beem 2007, Tjokropawiro 2010)

DM VEGF Ca cytosolic activity + eNOS Homing EPCAngiogensis # WH ulkus DM(Costanza et al2002, Pradhan et al2007,Singhan et al2007)

DFU proper managementHerbal therapy enhance angiogenesis

(Larijani et al2008)

5


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HIPERGLIKEMIA (DM)

bAGE

>1 week HEKSOSAMINE PATWAY (H) ARPKCROSTNF

NFB

NO NFB, eNO, TGFNAD(P)H OXIDASE

ET-1, PAI-1, VEGF

TGF,MMPs

CELL PROLIFERATION

SORBITOLGSH

TNF

OH+

TNF

GFAT

P A H A

STRESS OXIDATIVEINSULIN SENSITIVITY -CELL FUNCTION

PAHAM:PKC,AGE,HEKSOSAMINE,AR,MITOCONDRIAL DYSFUNCTION

MIKROANGIOPATI & MAKROANGIOPATI

TRAUMA VASCULOPATHY NEUROPATHY

MOTORIC SENSORY AUTONOM MICROPATHY MACROPATHY

WEAKNESS

ATROPHY

DEFORMITY

PLANTAR PRESSURE

CLAVUS

PROTECTION

SENSATION

ANHIDROSIS

DRY SKIN

FISSURE

SYMPATHY PRESSURE

ATEROSCLEROSIS

ISCHEMIA

BM CAPILLARY THICKENNING

A-V SHUNT

BLOOD FLOW

EDEMA NEUROPATHY

OSTEOARTHROPATHYRESPONSE TO INFECTION

NUTRITION

CAPILLARY BLOOD FLOW

HEMOSTASIS 1 HOUR #INFLAMMATION 2-7 DAYS #PROLIFERATIOM 2-20 DAYS #REMODELLING 6WEEK-3 MONTHS

GAMGGUAN PENYEMBUHAN ULKUS KAKI DMAMPUTASI AMPUTASI

#INFLAMMATION

NEUTROPHIL

MONOCYTE

ENDOTHELIAL DYSFUNCTION

# ANGIOGENESIS

KERATINOCYTES

PROLIFERATION

FIBROBLAST

GF

CITOKINES

SCHIFF BASE


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ALOE VERA

herbalhigh potency for diabetic woundhealing(Wendell, 2000).

Easy to find, antiinflammation (C-glukosylchromone), immune modulator, wound

nutrition (Wendell, 2000)

clinical Aloe gel modulate immunity,blood glucose stabilizer, pain ; arteriolardiameter (Somboonwong et al., 2000).

Aloe (gel): 98% water ;Acetylatedmannan>60% active compound 1 mg aloegel (acemanan 0,6mg) (Somboonwong et al,2000; Kusmawati,2007 )

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Acemannan-(1-4)-linked glukomanan acetylated and

manosaasetilasi residu

Polysaccharides doses 20 g/mL enhance WH, stimulatecellular proliferation,migration and cytokines production

Stimulate oxygen consumption, angiogenesis & sintesis (Lauraet al., 2002).

oral WH fibroblast proliferation and induceexpresssion ofKGF-1 and VEGF (Ramamoorthy, 1996; Hamman, 2008).

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Problem of the Study

herbal Aloe gelangiogenesisWH DM

wound healing VEGF expression

eNOS

EPC

CEC

EPC/CEC ratio

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Aim of the Study

PROVE :herbal Aloe gelangiogenesisWH DM

wound healing

VEGF expression

eNOS,

EPCCEC

EPC/CEC ratio

10


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ERK-1/2

ALOE GEL

VEGF

eNOS

EPC CEC

ANGIOGENESIS

DIABETIC WOUND HEALING

Cellular proliferation

CONCEPTUAL THEORY


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Aloe gel

Dose of30,60,120

(mg/day)

Diabetic wound

healing

wounddiameter

Angiogenesis

VEGF,eNOS ,EPC,CEC ,Rasio EPC/CEC

Expression and

amount

Hipotesis

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MATERIALS AND METHODS

Subject of study

Male strain wistar rats induced bySTZto makeDiabetic rats and wounded and treated by Aloe

veragel orally

Study Design

True experimental in vivo study designed by posttest only control grup design

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SCHEME OF STUDY PROTOCOL(ROCKET SYSTEM MODIFICATION, TJOKROPRAWIRO, 1978)

14

R

E

P

O

R

T

WOUND + ALOE

GEL 120 MG

WOUND + ALOE

GEL 60 MG

A

N

A

L

I

S

I

S

D

A

T

A

DAY

0 14

DM 0

DM120

DM 60

B0R

A

N

D

O

M

STRAI

N

WIS

TAR+ALOE

GEL

VEGF,eNOS,

EPC,CEC

WOUND

PRA

PENELITIAN

A : NORMAL RATSB : UNTREATED RATSC : DIABETIC RATS+TREATMENTD : DIABETIC RATS+TREATMENTE : DIABETIC RATS+TREATMENTPRE-STUDY: 0-14 days bedore treatment

STUDY : 0-14 hari after treatmentAle gel : glycoprotein and polysacchaarides aloe vera

VEGF :Vascular Endothelial Growth Factor

eNOS :endothelial Nitric Oxide Synthase

EPC :Endothelial Progenitor Cells

CEC :Circulating Endothelial Cells

VEGF : immunohistochemistry

eNOS : immunohistochemistryEPC : CD34 (Flowcitometri)

CECs : CD45(FITC)+CD146(PE)

(Flowcitometri)

wound : wound dimeter

Injection of STZ 60mg/kg (IP)

for 14 days (2 weeks)

Diabetes if blood glucose level >200mg/dl

NON

DMWOUND

WOUND + ALOE

GEL 30 MG

D14

PENELITIAN

140

280 14

N:15

n:3

n:3

MAIN PARAMETER

ketamin (10mg/kg/iv)

Wound diameter 2,5 cm depth 0,2 cm

Wash the wound with Nacl 0,9%

n:3

n:3

A0

D0

E0

VEGF,eNOS,

EPC,CEC

WOUND

HASILDATA

DATA

DATA

DATAA14

PRE- STUDY STUDY

DAY

MAKING OF DIABETIC RATS

MAKING OF WOUND

PARAMETER DATA ANALYSIS

C14

E14

SAMPLE POPULATION

p(t-1)(r-1) 15

t=treatmentr=repetition

DM 30C0

WOUNDB14 DATAn:3

Linear Regression

Anova (simple anova)

PRE- STUDY STUDY

D

A

T

A

A

N

A

LY

S

I

S

RESULT


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STUDY TIMELINE

PREMAKING OF ALOE GEL

MAKING OF DIABETIC RATS

studyStage I study

Effect of Aloe Gel wounddiameter

stage II study

(IMMUNOHISTOCHEMISTRY)

Effect of Aloe Gel Expression ofVEGF and eNOS

stage III study(FLOWCYTOMETRI)

Effect of Aloe Gel amount of EPC,CEC and EPC/CEC ratio

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RESULTS

14th

Day, measurement of : Wound diameter Immunohistochemistry of dermal tissue

Blood for Flowcitometry

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Measurement of Wound Diameter

Treatment n Mean SD (p 0,05)Normal Rats 3 1,100,14 (a

Diabetic Rats 3 1,190,12(a

Diabetic rats + 30 mg aloe

gel

3 0,320,01(b


gel

3 0,270,02(b

Diabetic rats + 120 mg

aloe gel

3 0,410,02(b

17p = 0.000

Normal Rats DM + 120 mgDiabetic rats DM + 30 mg DM + 60 mg


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Vascu lar Endo thel ial Grow th Factor(VEGF) Expression

treatment n Mean SD (p 0,05)Normal Rats 3 24,672,00 (a



gel

3 28,335,86(a


gel

3 34,675,03(a


gel

3 25,674,73(a

18p = 0.676

Normal Rats Diabetic Rats DM+30mg DM+60mg DM+120mg


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Endo thel ial Nitr ic Oxide Synthase(eNOS) Expression

Treatment n Mean SD (p 0,05)Normal Rats 3 24,671,73 (b



aloe gel

3 30,001,00(a


aloe gel

3 34,332,08(a


aloe gel

3 42,001,00(b

19p = 0.000

Normal RatsDM + 120

mgDiabetic rats DM + 30 mg DM + 60 mg


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Amoun t of Endothelial Progeni tor Cel ls(EPCs) CD 34

Treatment n Mean SD (p 0,05)Normal Rats 3 16,880,59 (a



aloe gel

3 10,649,34(a


aloe gel

3 12,111,16(a


aloe gel

3 13,751,63(a

Non DMhari ke-14(kontrol -)

DM hari ke-14(kontrol +)

DM + aloe gel 30 mghari ke-14



p = 0.457

n kelompok = 3

20

Normal RatsDM + 120

mgDiabetic rats DM + 30 mg DM + 60 mg


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Amount of Circulat ing Endo thel ial Cel ls(CECs) CD 45

Non DMhari ke-14(kontrol -)

DM hari ke-14(kontrol +)




21

p = 0.000

Normal Rats DM + 120 mgDiabetic rats DM + 30 mg DM + 60 mg

Treatment n Mean SD (p 0,05)Normal Rats 3 3,161,68(bc



aloe gel

3 7,361,22(b


aloe gel

3 4,890,83(bc


aloe gel

3 2,200,74(c


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PATH ANALYSIS

22


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DISCUSSION

Eff t d i i t ti f Al l d


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Aloe gel

Dosis

(mg/day) Diabeticwound healing

Wounddiameter

wound contraction

Effect administration ofAloe gel on wound

diameter

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Anti inflammatory

fibroblast proliferation collagen dan

glycosaminoglikan

synthesis

(Heggers 1993; Jia et al 2008;Kwack et al 2009 ,;Liu et al., 2010;

Fernanda et al., 2009;Jettanacheawchankit et al 2009)

Eff t d i i t ti f Al l E i f VEGF d


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Aloe gel

Dosis(mg/day) Diabeticwound healing

Wounddiameter

Angiogenesis

Effect administration ofAloe gel onExpression of VEGF and

eNOS Dermal Tissue

(Heggers 1993; Choi et al 2002; Tanimoto et al 2002;Duda et al 2004;

Young et al 2004;Kim et al 2007;Pradhan et al. 2007; Beem et al. 2007;

Singhan et al 2007; Chen et al 2007).

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VEGFeNOS

EPC mobilization

Eff t d i i t ti f Al l t f


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Aloe gel

Dosis

(mg/day)

Diabeticwound healing

Wounddiameter

Angiogenesis

Effect administration of Aloe gel on amount of

EPCs and CECs circulation

Spinetti et al. 2008;Albiero et al., 2011;Oren et al., 2010;McClung et al

2005;Fiorina et al. 2010;Sibal et al 2009;Spinetti et al 2008;Nababan et al.,

2007;Boos et al 2006

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migration/Homing EPCCECs


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EPC/CEC RATIO AFTER ADMINISTRATIONOF ALOE GEL

aloe gel herbal pro-angiogenic keep survival

EPCs during mobilization and hom ing into woundincrease amount of EPCs to damage

endothelial cells from vascular wall (CECs).

Treatment Mean SD (p 0,05)

Normal rats 6,53,41 (cDiabetic rats 0,720,1(a


gel

2,180,16(ab

Diabetic rats + 60 mg aloegel

2,510,84(ab


gel

6,351,99(c


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Aloe gel

Dose

120(mg)

wound healing

wounddiameter

cm2

Angiogenesis

VEGF,eNOS,EPC,CEC

Exresion (ng/ml)

and amount

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Ratio

EPC/CEC Hipotesisstatisticallyproved

(P


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30


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HEALTHY WOUND DIABETIC WOUNDTHE ROLES OF HSP 70 / HSP 72

on Wound Healing


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Mekanisme Penyembuhan luka Normal dibanding Diabetes (Beem et al 2007, Tjokropawiro 2011)

DM WITH 5 DYSFUNCTION : KERATINOCYTE, PLATELET,ENDOTHELIUM, MACROPHAGE, MYOFIBROBLAST

Blood Glukose

Should be

aloe gel asmiha

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