ZhiXiaoSanZheng formula ameliorates podocyte injury in diabetic kidney disease by inhibiting ferroptosis: integrated network pharmacology and experimental validation

Abstract Background Diabetic kidney disease (DKD) is widely recognized as a major contributor to end-stage renal disease, in which podocyte injury serves as an important pathological basis for disease progression. ZhiXiaoSanZheng Formula (ZXSZF), an empirically derived traditional Chinese medicine prescription, has shown therapeutic potential in DKD; however, its molecular mechanisms remain unclear. This study investigated whether ZXSZF protects podocytes by modulating ferroptosis-related pathways. Methods The chemical profile of ZXSZF was analyzed by LC–MS/MS. Potential bioactive compounds were screened through SwissADME, and putative targets were predicted using SwissTargetPrediction. Overlapping targets among ZXSZF, DKD, and ferroptosis were identified and analyzed through protein–protein interaction and functional enrichment analyses. The predicted mechanisms were further validated in a unilateral nephrectomy plus STZ-induced DKD rat model and in AGEs–stimulated MPC5 podocytes. Results LC–MS/MS analysis identified 94 chemical constituents in ZXSZF. Network pharmacology analysis suggested that antioxidant and ferroptosis-related pathways centered on NRF2 may represent potential regulatory nodes of ZXSZF. In DKD rats, ZXSZF reduced albuminuria and improved renal histopathological changes, accompanied by restoration of podocyte markers and attenuation of ferroptosis-associated alterations. In AGEs-stimulated podocytes, ZXSZF decreased lipid peroxidation and iron accumulation while enhancing cellular antioxidant capacity. These effects were associated with increased NRF2 signaling and upregulation of SLC7A11 and GPX4. Pharmacological inhibition of NRF2 with ML385 partially attenuated the protective effects of ZXSZF. Conclusions ZXSZF alleviates podocyte injury in DKD and its renoprotective effects are associated with modulation of ferroptosis-related processes involving the NRF2/SLC7A11/GPX4 pathway. The present study provides experimental evidence for the mechanistic basis of ZXSZF and supports its potential role as a complementary therapeutic option in DKD management. Graphical abstract