Therapeutic effect of Huzhangoside D in rats with knee osteoarthritis induced by anterior cruciate ligament transection
Ruo Jing Zhang1, Cheng Chen Cai2, Jian Pang3, Xiao Li Xu2, Hai Xin Gou2, Guo Wen Li1
1 Department of Pharmacy, Shanghai TCM.Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
2 Department of Traditional Chinese Medicine, HuaDong Hospital, FuDan University, Shanghai, China
3 Shi's Center of Orthopaedics and Traumatology, ShuGuang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
|Date of Submission||20-Jul-2020|
|Date of Decision||09-Sep-2020|
|Date of Acceptance||05-Jan-2021|
|Date of Web Publication||15-Apr-2021|
Hai Xin Gou
No. 221, Yan'An West Road, Shanghai, 200040
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Knee osteoarthritis (KOA) is an age-related disease. Huzhangoside D is a saponin isolated from genus Clematis L. (Ranunculaceae). The aim of this study is to explore the anti-inflammatory, apoptotic, and autophagy regulation effects of huzhangoside D on KOA in a rat model. Materials and Methods: The KOA model was established by an anterior cruciate ligament transection surgery. Huzhangoside D was administered for 4 weeks. The weight-bearing assay, morphology observation, and intrinsic mechanism exploration were performed. Results: After administration, the weight-bearing assay showed that huzhangoside D promoted joint function recovery. Hematoxylin-eosin and safranin O-Fast green staining indicated that huzhangoside D ameliorated the structural damage. The Mankin scores were decreased in the huzhangoside D groups. Huzhangoside D enhanced cartilage thickness. Enzyme-linked immunosorbent assay study revealed that huzhangoside D downregulated the proinflammatory cytokine (tumor necrosis factor alpha, interleukin-6, and interleukin-1β) levels, while it upregulated the anti-inflammatory cytokine (interleukin-10) level in rat serum. Terminal deoxynucleotidyl transferase dUTP nick end labeling assay showed that huzhangoside D downregulated the apoptosis ratio of cartilage cells. Immunohistochemical staining showed that huzhangoside D upregulated the autophagy-related protein beclin-1, ATG5, ATG7, and light chain 3 levels and downregulated the p62 level. Moreover, the AKT and mTOR signaling pathway activities were downregulated. The 3-MA combination with huzhangoside D downregulated the weight-bearing function and morphology of the knee and upregulated the proinflammatory cytokines, which showed the role of autophagy as a protective mechanism in the effect of huzhangoside D. Conclusion: This study revealed that huzhangoside D is a promising agent in KOA treatment.
Keywords: Agent, apoptosis, autophagy, huzhangoside D, inflammation, knee osteoarthritis
|How to cite this article:|
Zhang RJ, Cai CC, Pang J, Xu XL, Gou HX, Li GW. Therapeutic effect of Huzhangoside D in rats with knee osteoarthritis induced by anterior cruciate ligament transection. Phcog Mag 2021;17:112-9
|How to cite this URL:|
Zhang RJ, Cai CC, Pang J, Xu XL, Gou HX, Li GW. Therapeutic effect of Huzhangoside D in rats with knee osteoarthritis induced by anterior cruciate ligament transection. Phcog Mag [serial online] 2021 [cited 2022 Jan 19];17:112-9. Available from: http://www.phcog.com/text.asp?2021/17/73/112/313497
- In this study, we explored the pharmacological effects of a natural saponin, huzhangoside D, in the anterior cruciate ligament transection-induced knee osteoarthritis (KOA) rat model and the underlying molecular mechanisms. Huzhangoside D promoted the joint function recovery and ameliorated the histological change in cartilage loss in KOA rats. This effect was mediated by the anti-inflammatory, anti-apoptotic, and autophagy regulation abilities of huzhangoside D. This study showed that huzhangoside D is a promising agent for KOA therapy.
Abbreviations used: ACLT: Anterior cruciate ligament transection; KOA: Knee osteoarthritis; IOD: Integrated optical density; IHC: Immunohistochemical; LC3: Light chain 3; ELISA: Enzyme-linked immunosorbent assay; TNF-α: Tumor necrosis factor alpha, IL-6: Interleukin-6; IL-10: Interleukin-10; IL-1β: Interleukin-1β; TUNEL: Terminal deoxynucleotidyl transferase dUTP nick end labeling.
| Introduction|| |
Osteoarthritis (OA) is an age-related disease, which affects about a quarter of the middle-aged people and most of the elderly people. The most commonly affected joints in OA are the knee and hip. The main symptoms of knee osteoarthritis (KOA) are pain, knee swelling, and physical disability, which cause a gradual loss of walking ability. In many countries, KOA causes an unaffordable economic burden and healthcare costs to the families and society. Inflammation plays a crucial role in KOA. Proinflammatory cytokines are generated from inflammatory cells and synovial cells under the circumstance, and they consequently stimulate the production of proteolytic enzymes. The characteristic pathological features of KOA are articular cartilage degeneration and chondrocyte death under the stimulation of biochemical, biomechanical, and even genetic changes in knee joints, especially in cartilage. The only type of cell that exists in the cartilage is the chondrocyte. Under stimulation, the chondrocytes are subjected to gradual degradation and death. Cell death can be divided into several types, and the most common type is apoptosis. Current pharmacological therapies, such as nonsteroidal anti-inflammatory drugs and glucosamine, are limited and palliative because treatment only focuses on anti-inflammation and apoptosis in the chondrocytes.
Autophagy is a conservative mechanism of cell self-protection, which plays an important role in maintaining metabolism and internal environment stability in cells. Autophagy is mainly characterized by the compromise of autophagosomes and lysosomes to create autolysosomes. Intracellular contents, including damaged and dysfunctional macromolecules and organelles in autolysosomes, are then degraded by lysosomal enzymes. Numerous autophagy-related genes, including microtubule-associated protein 1 light chain 3 (LC3), ATG, beclin-1, and sequence 1 (sqstm1/p62), are involved in autophagy under a stimulated environment. Accumulating reports have revealed that autophagy is tightly associated with inflammation, metabolism, and apoptosis in KOA. Hence, a pharmacological intervention should be developed to focus not only on anti-inflammation and chondrocyte apoptosis but also on autophagy regulation in chondrocytes.
Bioactive compounds from the plants are favored because plants provide a variety of resources, especially plants that have been commonly applied in the past in folk medicine. They can provide an effective drug by screening and diminishing the chemical establishment procedures. Numerous plant compounds have been validated for their efficacy in OA. Huzhangoside D [Figure 1]a is a saponin isolated from genus Clematis L. (Ranunculaceae), as an example Clematis graveolens. The genus Clematis L. (Ranunculaceae) plants consist of 295 species and plants worldwide. They have been employed to treat inflammation in folk medicine. Although huzhangoside D has been found about 20 years ago, its pharmacological effect is not fully known to date. A study exhibited the anticancer effect of huzhangoside A, a similar structure compound, by the inhibition of the pyruvate dehydrogenase kinase activity. The aim of this study is to explore the anti-inflammatory, apoptotic, and autophagy regulation effects of huzhangoside D on KOA in a rat model.
|Figure 1: The chemical structure and behavior assay of huzhangoside D in knee osteoarthritis rats. (a) The chemical structure of huzhangoside D. (b) The weight-bearing assay. The statistical difference among the anterior cruciate ligament transection model group and other groups was considered significant at the level of **P < 0.01 or ***P < 0.001. The statistical difference among 68 mg/kg group and 68 mg/kg + 3-MA group was considered significant at the level of ***P < 0.001. ACTL: Anterior cruciate ligament transection|
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| Materials and Methods|| |
Quantitation enzyme-linked immunosorbent assay (ELISA) kits of tumor necrosis factor alpha (TNF-α), interleukin-6 (IL-6), interleukin-10 (IL-10), and interleukin-1β (IL-1β) were obtained from Beyotime Institute of Biotechnology (Nantong, JiangSu, China). Huzhangoside D standard was obtained from Nature-Standard Corporation (>98%, Nature-Standard, Shanghai, China). Mild decalcification solution was purchased from Sigma-Aldrich (St. Louis, MO, USA). The TransDetect® In Situ Fluorescein Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) Cell Apoptosis Detection Kit was provided by Roche (Roche, Basel, Switzerland). Primary antibodies and secondary antibodies were obtained from Abcam (Abcam plc, Cambridge, UK).
Animal, surgery, and treatment
All animal experiments in this study were performed following the Declaration of Helsinki, and procedures were approved by the Institutional Animal Care and Use Committee of Shanghai University of Traditional Chinese Medicine (PZSHUTCM190906003). Sprague–Dawley (SD) rats (150–160 g, 6 weeks, specific pathogen-free [SPF], healthy, and males) were obtained from Shanghai SIPPR-Bk Laboratory Animals Ltd and housed in the Shanghai University of Traditional Chinese Medicine with a temperature of 20°C–25°C, humidity of 40% ± 5%, and 12-h light/12-h dark cycle environment at SPF grade. Rats were maintained in a cage with bedding of sawdust and free to diet and water. After 7 days of accommodation, 42 rats were randomized and divided into seven groups (n = 6): sham group as normal control (sham group), one model group that underwent anterior cruciate ligament transection surgery (ACLT model group), three groups that underwent ACLT surgery and were treated with huzhangoside D at three increasing doses, one positive group that received glucosamine sulfate (positive group, 200 mg/kg/day), and one huzhangoside D group (68 mg/kg/day) combined with the 3-MA (an autophagy inhibitor, 15 mg/kg/day). ACLT surgery was performed using pentobarbital sodium 40 mg/kg i.p. at first following previous literature. After that, anesthesia was maintained under a mixture gas of O2 and isoflurane 2.5% from a small animal anesthesia machine (SAR-1000, Bioseb, Vitrolles, France). The anterior cruciate ligament was carefully transected in the right knee to avoid injury to the other muscles and ligaments. In the sham group, the wounds were sutured after exposing the knee joint cartilage surface at the same position. After surgery, rats were subjected to the drawer test to ensure the success of the operation. Meanwhile, one million units of penicillin (Yansheng, Shanghai, China) was intramuscularly injected in each rat for 3 days to avoid infection. Huzhangoside D was dissolved in PBS and injected i.p. into the rats at a dose of 17, 34, and 68 mg/kg daily in the huzhangoside D groups for 4 weeks. An equivalent volume vehicle was injected into the rats in the ACLT model group.
The weight-bearing distribution test was employed to investigate the joint weight-bearing function using a dynamic weight-bearing instrument (Taimeng, Chengdou, China) following previously described methods., Concisely, a dual-channel weight average was employed to investigate the weight borne by the two hind paws per week. The index of joint discomfort and function was calculated as the ratio of the experimental hind paw (right) to total hind paws (right + left). Weight-bearing tests were performed two times at an interval of 10 min and recorded as the mean of two trials. The weight-bearing test was initiated at −1 week from ACLT surgery to the last administration of huzhangoside D at 4 weeks.
Enzyme-linked immunosorbent assay
About 24 h after the behavior assay, rats were executed using cervical dislocation under anesthesia. Then, the serum of rats was collected immediately, and the proinflammatory (TNF-α, IL-1β, and IL-6) cytokine and the anti-inflammatory IL-10 cytokine levels in the serum were detected following the manufacturer's method.
The right knee joints of rats were fixed in 4% paraformaldehyde after dissection for 24 h, washed three times using PBS, and decalcified in mild decalcification solution for approximately 5 weeks with continuous solution exchange per week. Decalcification was complete when the needle could pass the tissues easily without any obvious resistance. After that, joint tissues were embedded in paraffin wax and cut into 5 μm sections. Hematoxylin-eosin (HE) staining and safranin O-Fast green staining (1% safranin O counterstained with 0.75% hematoxylin and then 1% Fast Green, Service bio, Wuhan, China) were conducted to visualize the structural changes of cartilage and proteoglycan content in the cartilage using a light microscope (MF31, Mshot, Guangzhou, China). Semi-quantitative histopathological grading of the structure was performed by a third-party pathologist following a modified Mankin scoring system concerning the structure. Masson staining (Servicebio, Wuhan, China) was employed to identify the type II collagen fibers. Toluidine blue staining was employed to investigate the cartilage thickness.
Terminal deoxynucleotidyl transferase dUTP nick end labeling assay
TUNEL assays were employed to detect apoptosis in situ according to a previous report and manufacturer's instructions. Briefly, 5 μm sections of the joint tissue were soaked with dimethylbenzene and subjected to gradient dehydration (100%, 95%, 90%, 80%, and 70% alcohol). Then, the sections were digested with proteinase K (Dako, Glostrup, Denmark) action solution for 15 min and incubated with terminal deoxynucleotidyl transferase action solution at 37°C for 1 h. Furthermore, sections were counterstained with 4',6-Diamidino-2-Phenylindole (DAPI). The images of the approximate region of the joint were visualized by a slide-driver fluorescence microscope (3D Histech Ltd., Budapest, Hungary) at an excitation wavelength of 468 nm. The percentage of apoptotic chondrocytes was evaluated as the green fluorescence of cartilage versus blue nuclei (DAPI).
Immunohistochemical (IHC) analysis was performed on the articular cartilage to investigate the expressions of related signaling pathway and autophagy-related proteins. As mentioned above, the joint sections were cut into 5 μm sections. The joint sections were incubated overnight at 4°C with rabbit polyclonal antibodies developed against the desired proteins (beclin-1:Ab62557, 1:100; ATG5:Ab103827, 1:100; ATG7:Ab133528, 1:100; p62:Ab56416, 1:100; LC3B:Ab48394, 1:100; p-mTOR:Ab84400, 1:100; p-AKT: Ab38449, 1:100). Immune complexes were then incubated with the anti-rabbit HRP-conjugated secondary antibody for 20 min at 37°C. The images of the approximate region of the joint were captured using a microscope (MF31, Mshot, Guangzhou, China). The integrated optical density and area of immunostaining were assessed using Image-Pro Plus 6.0 image analysis software (Media Cybernetics Co., USA).
Results of the animal study were expressed as means ± standard deviation and determined using one-way ANOVA to assess statistical significance. P < 0.05 was considered statistically significant. All statistical analyses were conducted using commercially available statistical software (SPSS 22.0, Chicago, IL, USA) and presented by GraphPad Prism 6.0 (GraphPad Software Inc., Diego, CA, USA).
| Results|| |
Huzhangoside D promoted the recovery of joint function and ameliorated the pain in KOA rats. First, during the total animal study, there were no toxic signs, such as diminished activity, vomiting, bleeding, or death, when doses of 17, 34, and 68 mg/kg huzhangoside D were administered. All rats maintained good-eating and normal activity. Weight-bearing test was employed to investigate the endurance of knee function. [Figure 1]b shows that weight bearing of the right limb was nearly 50% at −1 week, suggesting that left and right knee function was balanced among all groups. After ACLT surgery, weight bearing of the right limb was decreased in KOA model rats. Huzhangoside D at doses of 17, 34, and 68 mg/kg/day ameliorated the decrease gradually [Figure 1]b, demonstrating that huzhangoside D promoted the recovery of right knee joint function.
Huzhangoside D ameliorated the histological assay of the cartilage
HE staining [Figure 2]a and safranin O-Fast green staining [Figure 2]b indicated the histological changes among the seven groups. The ACLT model group showed changes, which were classified as inflammatory infiltrates, angiogenesis, edema, pannus formation and granuloma, focal loss of cartilage, bone erosion, and presence of extra-articular inflammation. However, huzhangoside D treatment alleviated the damage. Mankin scores were increased in the ACLT model group compared with the sham group. After huzhangoside D administration, Mankin scores were decreased in huzhangoside D groups compared with the ACLT model group [Figure 2]e. Moreover, huzhangoside D also enhanced cartilage thickness [Figure 2]c, which suggested that huzhangoside D ameliorates the symptoms of KOA. Furthermore, Masson's staining also showed disorganized collagen fibers in the ACLT model group, while the collagen fibers were well arranged in the huzhangoside D groups [Figure 2]d.
|Figure 2: The morphology assay of huzhangoside D in knee osteoarthritis rats. (a) Hematoxylin-eosin staining of knee joint cartilage. (b) Safranin O-fast green staining. (c) Masson's staining. (d) Toluidine blue staining. (e) Mankin scores among groups. Scale bar = 200 μm. The statistical difference among the anterior cruciate ligament transection model group and other groups was considered significant at the level of **P < 0.01 or ***P < 0.001. The statistical difference among the 64 mg/kg model group and 64 mg/kg + 3-MA group was considered significant at the level of ***P < 0.001. ACTL: Anterior cruciate ligament transection|
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Huzhangoside D downregulated the proinflammatory cytokine levels in the serum
ELISA assay showed the proinflammatory cytokine level changes in the serum of SD rats. Proinflammatory cytokine levels (TNF-α, IL-1β, and IL-6) were increased in the ACLT model group compared with the sham group. Huzhangoside D administration attenuated the increase in proinflammatory cytokines, as shown in [Figure 3]a, [Figure 3]b, [Figure 3]c. These results showed that huzhangoside D has an inhibitory effect of inflammation. Meanwhile, huzhangoside D upregulated the IL-10 anti-inflammatory cytokine level [Figure 3]d.
|Figure 3: Inflammatory cytokine levels in rat serum. (a) The expression level of interleukin-1β. (b) The expression level of interleukin-6. (c) The expression level of tumor necrosis factor alpha. (d) The expression level of interleukin-10. The statistical difference among the anterior cruciate ligament transection model group and other groups was considered significant at the level of *P < 0.05, **P < 0.01, or ***P < 0.001. The statistical difference among the 64 mg/kg model group and 64 mg/kg + 3-MA groups was considered significant at the level of **P < 0.01 or ***P < 0.001. ACTL: Anterior cruciate ligament transection; TNF-α: Tumor necrosis factor alpha, IL-6: Interleukin-6; IL-10: Interleukin-10; IL-1β: Interleukin-1β|
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Huzhangoside D downregulated the apoptosis of cartilage cells
As shown in [Figure 4], apoptotic chondrocytes with green fluorescence were apparently increased in the ACLT-induced KOA model. However, after 4 weeks of huzhangoside D administration, the apoptosis ratios in administration groups were decreased, especially in the 68 mg/kg group. TUNEL assay showed that huzhangoside D downregulated the apoptosis ratio of cartilage cells [Figure 4].
|Figure 4: Terminal deoxynucleotidyl transferase dUTP nick end labeling staining of chondrocyte apoptosis. Scale bar = 50 μm. The statistical difference among the anterior cruciate ligament transection model group and other groups was considered significant at the level of ***P < 0.001. ACTL: Anterior cruciate ligament transection; TUNEL: Terminal deoxynucleotidyl transferase dUTP nick end labeling|
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Huzhangoside D upregulated the autophagy-related proteins and role of the AKT-mTOR signaling pathway
Moreover, IHC studies showed that huzhangoside D upregulated the autophagy-related protein beclin-1, ATG5, ATG7, and microtubule-associated protein 1 LC3B levels in the cartilage compared with the ACLT model group, as shown in [Figure 5]a, [Figure 5]b, [Figure 5]c, [Figure 5]d, indicating that huzhangoside D promoted the autophagy levels in the cartilage. Meanwhile, the level of another autophagy-related protein p62 was downregulated in [Figure 5]e. Moreover, p-mTOR and p-AKT levels were inhibited in the huzhangoside D groups compared with the ACLT model group, as shown in [Figure 5]f and [Figure 5]g.
|Figure 5: The autophagy-related protein expression in rat knee osteoarthritis bone cartilage using immunohistochemical assay. (a) Beclin-1 expression. (b) ATG5 expression. (c) ATG7 expression. (d) LC3 expression. (e) P62 expression. (f) p-AKT expression. (g) p-mTOR expression. Scale bar = 200 μm. The statistical difference among the model group and other groups was considered significant at the level of *P < 0.05, **P < 0.01, or ***P < 0.001. ACTL: Anterior cruciate ligament transection|
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Role of autophagy in the pharmacological effect of huzhangoside D
In addition, 3-MA, a well-known autophagy inhibitor, was injected to validate the role of autophagy in the pharmacological effect of huzhangoside D. Compared with the sole administration of huzhangoside D (68 mg/kg), combined administration of huzhangoside D and 3-MA weakened the improved effect on the weight-bearing ability [Figure 1]b. Furthermore, combined administration with 3-MA worsened the knee joint morphology [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d and upregulated the inflammatory cytokines [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d. This result confirmed that huzhangoside D induced autophagy as an important protective mechanism.
| Discussion|| |
To date, many drugs derived from plants have been screened, and their efficacy has been confirmed in the preclinical study. In this study, huzhangoside D, a saponin compound, rarely studied in the past was found to show anti-inflammatory, apoptotic, and autophagy regulation effects in an ACLT-induced KOA rat model.
Some study has revealed the association between worse joint function and high levels of joint degeneration biomarkers, for instance, high levels of TNF-α, IL-6, and IL-1β. The articular cartilage is composed of chondrocytes and extracellular matrix. Chondrocytes are responsible for tissue maintenance, which has an impact on joint function and performance. IL-1β and TNF-α are inflammatory mediators involved in joint degeneration caused by KOA. Inhibition of these proinflammatory cytokines in the knee joint can elicit the synthesis of proteoglycans and collagen, and then, it can inhibit joint swelling. IL-10 expression plays a key role in anti-osteoclastogenesis, and it is downregulated in OA patients. In this study, huzhangoside D inhibited the increase in proinflammatory cytokines in the ACLT-induced KOA rat model, demonstrating that huzhangoside D is a promising anti-inflammatory compound. Moreover, autophagy is tightly linked with inflammation in tissues, especially in OA. Generally, autophagy can regulate inflammation. Absence of B-cell autophagy inhibited the production of inflammatory cytokines. Meanwhile, autophagy of the immune system affects T-cell proliferation and survival. The inhibition of mTOR, an autophagy-related signaling pathway, resulted in a decrease in cartilage injury and reduced secretion of the synovial inflammatory cytokines, such as IL-1β and TNF-α.
Meanwhile, autophagy is a protective mechanism that can help chondrocytes to adapt to various stresses in the joint. As KOA is a bone degradation disease, autophagy can digest the necrotic organelles in chondrocytes, thus suppressing damage and maintaining the cellular metabolism. Accumulating reports have revealed that autophagy is indispensable for chondrocytes, and autophagy deficits play crucial roles in the pathogenesis of KOA. Atg5 and LC3 were markedly downregulated in the cartilage of aging mice. In addition, lower levels of autophagy-related proteins aggravated the cartilage loss and apoptosis. Hence, regulation of autophagy is an important cellular target of new drug development. Many new drugs, treatment, and physical therapy have been developed to promote the autophagy levels against KOA development. For instance, the treadmill exercise enhanced the autophagy-related protein levels; thus, ameliorating the KOA scores in a KOA rat model, adipose-derived mesenchymal stem cells elicited the autophagy and helped the recovery from KOA., Curcumin and BST106 alleviated the cartilage impair in KOA in vivo. On the contrary, microRNA-128a downregulated the chondrocyte autophagy levels, thus exacerbating KOA. There are many biomarkers of autophagy in chondrocytes, such as Unc-51-like kinase 1, beclin-1, microtubule-associated protein 1 LC3, ATG7, and ATG5. Beclin-1, which is also named BECN1, is a key regulator of autophagy in the cartilage. The activation of p62 is tightly linked with the inhibition of autophagy. Huzhangoside D inhibited the activation of p62 in this study. Most importantly, LC3 is an essential autophagy-related protein, which indicated the formation of an autophagosome directly. In this study, huzhangoside D promoted the upregulation of autophagy-related proteins, LC3B, ATG5, ATG7, and beclin-1. Numerous signaling pathways, such as MAPK signaling pathway, NF-kappa B signaling pathway, and PI3K/AKT signaling pathway, were involved in the autophagy regulation in vitro and in vivo. Among them, the AKT/mTOR signaling pathway was frequently involved and commonly exerted a protective effect.,, The phosphorylation of AKT and downstream mTOR signaling pathway could elicit the upregulation of autophagy. In this study, huzhangoside D downregulated the p-AKT/p-mTOR expression levels and elicited the upregulation of autophagy-related protein levels.
| Conclusion|| |
To sum up, the in vivo pharmacological effects of huzhangoside D in the ACLT-induced KOA rat model and the underlying molecular mechanisms were investigated. In this study, huzhangoside D promoted the joint function recovery and ameliorated the histological change in cartilage loss in KOA rats. This effect was mediated by the anti-inflammatory, anti-apoptotic, and autophagy regulation abilities of huzhangoside D. Therefore, huzhangoside D is a promising agent for KOA treatment.
Financial support and sponsorship
This study was supported by Shanghai Science and Technology Commission Project (No. 18401901700).
Conflicts of interest
There are no conflicts of interest.
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