|Year : 2020 | Volume
| Issue : 2 | Page : 70-74
Management of microalbuminuria in Stage-2 Diabetic Nephropathy by Ayurveda formulation and Pathya ahara (Plant- based diet): A case report
Manisha Shukla, Vyasadeva Mahanta, Rahul Sherkhane, Sanjay Kumar Gupta
Department of Shalya Tantra, All India Institute of Ayurveda, New Delhi, India
|Date of Submission||01-Apr-2020|
|Date of Acceptance||04-Jul-2020|
|Date of Web Publication||16-Oct-2020|
Dr. Vyasadeva Mahanta
Department of Shalya Tantra, All India Institute of Ayurveda, New Delhi
Source of Support: None, Conflict of Interest: None
Microalbuminuria is one initial diagnostic marker of progressive Diabetic Nephropathy (DN). Urine Albumin Excretion (UAE) between 30 and 300 mg/24 h is found in Stage 2 DN. In Ayurveda, no description is found, which can be directly correlated with DN, but Nidana and Samprapti of Prameha can be correlated for its manifestation. In this case, a 56-year-old male patient visited to Shalya Tantra OPD with complaints of type 2 diabetes and 135 mg UAE in 24 h with estimated Glomerular Filtration Rate (eGFR) of 77 ml/min/1.73 m2. This case report was aimed to evaluate the effect of Ayurveda formulations (Gokshuradi guggulu, Haritakyadi kwatha, Bhumyamalaki churna, and Gokshura churna) with Pathya ahara (Plant-based diet) in the management of microalbuminuria in DN Stage 2. This formulation was given for one month and Pathya ahara advised for two months. UAE significantly decreased and came to normoalbuminuria state. eGFR increased up to 87 ml/min/1.73 m2. The present study suggested that using Ayurveda formulations with Pathya ahara is effective in the management of microalbuminuria in DN Stage 2.
Keywords: Microalbuminuria, Nephropathy, Pathya ahara
|How to cite this article:|
Shukla M, Mahanta V, Sherkhane R, Gupta SK. Management of microalbuminuria in Stage-2 Diabetic Nephropathy by Ayurveda formulation and Pathya ahara (Plant- based diet): A case report. J Ayurveda Case Rep 2020;3:70-4
|How to cite this URL:|
Shukla M, Mahanta V, Sherkhane R, Gupta SK. Management of microalbuminuria in Stage-2 Diabetic Nephropathy by Ayurveda formulation and Pathya ahara (Plant- based diet): A case report. J Ayurveda Case Rep [serial online] 2020 [cited 2020 Dec 3];3:70-4. Available from: http://www.ayucare.org/text.asp?2020/3/2/70/298291
| Introduction|| |
Diabetes associated with microvascular complications and organ damage depends on the duration and severity of hyperglycemia. Microalbuminuria is one of the initial diagnostic marker of progressive Diabetic Nephropathy (DN). Urine Albumin Excretion (UAE) between 30 and 300 mg/24 h is found in Stage 2 of DN. [Table 1]. Abnormal UAE occurs in 30%–40% of type 2 diabetic patients and may develop into chronic kidney disease in the later stage, and on progression, it leads to death due to the involvement of cardiovascular diseases. Previous study reported that 30-40% of Diabetes Mellitus patients develops Kidney disease after 10-20 years duration. Early detection and treatment are essential in diabetes to check the excretion of albumin and progress of nephropathy. DN is a leading cause of chronic kidney failure starting with normoalbuminuria, microalbuminuria, macroalbuminuria, and ultimately leading to end-stage renal disease.
According to Ayurveda, DN may be considered as a disease of Mutravaha srotas. It is manifested due to derangement of Tridosha (~three humors)that affect Mutravaha Srotas with their respective signs and symptoms. Prameha (~diabetes) is mentioned as a Vyadhi of Mutravaha srotas, and Bahudravasleshma dosha is a comorbid element responsible for Prameha. It is correlated with diabetes in the modern medicine. The root source of Mutravaha srotas is Vankshana (~inguinal region) and Basti (~urinary bladder), As per commentator views, Vankshan is considered as Vrikka (~kidney). These two organs are primarily affected in Prameha. Hence, Pramehajanya vrikka vikara can be correlated with DN. As mentioned in Charaka Samhita, if any disease is not described in the classical text, it can be managed by applying fundamental principles related to pathology and treatment given in Ayurveda.
As per the standard treatment protocol for the management of Diabetes Mellitus (DM) and its complications through Ayurveda in 2017, the medicines Gokshuradi guggulu, Haritakyadi kwatha, Bhumyamalaki churna, and Gokshura churna are recommended for DN Stage 1 and 2. In this case report, these medicines were given for a period of one month to evaluate the efficacy on microalbuminuria. As per Ayurveda, specific guidelines about diet are given to prevent and eradicate the disease. Acharya Charaka has mentioned that Pathya ahara (~suitable food) is useful for human well-being while Apathya ahara (~unsuitable food) is the root cause of all diseases. Acharya Kashyapa has described food as Mahaausadha (~best medicine). Drug cannot fulfil the benefits of food in diseased state. Similarly, Lolimbaraj has stated that if a person follows the Pathya (~dietary rule), there is no requirement of drug for treatment and drug has no value when a person is not followed the Pathya. Acharya Charaka has given the concept of Shakavarga (~plant-based diet) which provides the nutritional requirements. The Plant Based diet (PBD) in raw form has the ability to reduce blood glucose levels both fasting and postprandial. Increased UAE is one important pathological finding which is found in the early stage. In Ayurveda classic, many formulations are mentioned to correct urinary abnormality. In presented case, increased UAE came to normal range within two months of using Ayurveda formulations and especially designed PBD, which showed beneficial effect by checking further progression of DN.
| Case Report|| |
A 56-year-old male patient, visited Shayla Tantra OPD, with complaints of increased frequency of micturition, 4–5 times at night, turbid urine, numbness in bilateral lower limbs, and general weakness for six months. He was diagnosed with type 2 Diabetes before six months when his fasting blood glucose was 150 mg/dl and postprandial glucose was 180 mg/dl. He was under Ayurvedic medication with Jambubeeja churna in dose of 3 g twice a day after meals and Nishakathkadi kwatha in a dose of 10 g twice a day after meals. He was not taking any conventional medicines. There was no history of other illness. On physical examination, it was revealed that his pulse was 80/min and regular, blood pressure was 130/90 mmHg. On biochemical investigation, serum creatinine was 1.06 mg/dl, UAE was 135 mg/24 h, urinary creatinine was 987 mg/24 h with estimated Glomerular Filtration Rate (eGFR) 77 ml/min/1.73 m 2, creatinine clearance rate was 74.84 ml/min, fasting blood glucose level was 109 mg/dl and postprandial blood sugar was 135 mg/dl [Table 2]. Based on the history and biochemical investigations, he was provisionally diagnosed with a case of DN stage 2.
| Timeline|| |
Treatment was initiated after taking written informed consent. Gokshuradi guggulu 1 gm (thrice a day) with warm water after food, 40 ml Haritakyadi kwatha twice a day on empty stomach 1 h before meal, 3 g Bhumyamalaki churna + 3 g Gokshura churna three times a day with water after food for one month were prescribed [Table 2]. He was also advised to consume PBD that includes seasonal fruits 1% of his body weight on empty stomach at morning hours and salad (seasonal raw vegetables) 0.5% of his body weight before lunch and dinner for two months. Concept of Pathya is mentioned in Ayurveda, but the description of consumption of fruits and vegetables (Salad) before meals is not mentioned as such in Ayurveda. This concept is also supported by modern literature which is evidenced by the many modern research papers. In this study, an effort was made to validate the concept of Ahar and Vihar, which are the only factors responsible for causing any disease as per Ayurveda. He was strictly advised to avoid packed and refined food, nutritional supplements, animal and dairy products, and dinner at late hours. The patient was allowed to continue Ayurveda antidiabetic medicines.
| Follow up and Outcome|| |
The patient was followed for one month after the completion of treatment. UAE was decreased up to 40.70 mg/24 h, and after two months, UAE reduced up to 23.10 mg/24 h which is physiological normal range. Urinary creatinine was increased up to 1544 mg/24 h after one month and 1532 mg/24 h after two months. Serum creatinine was decreased from 1.06 mg/dl to 0.95 mg/dl after one month and 0.92 mg/dl after two months without support of conventional medicines. eGFR and creatinine clearance were increased which indicates the improvement of renal function as a whole but sonologically not evaluated [Table 3].
| Discussion|| |
Initial detection of microalbuminuria in diabetes is a primary target to prevent nephropathy. If disease progress is checked at the stages of 1 and 2 by Ayurvedamedication, the interventions such as frequent dialysis, renal replacement which is indicated for 3rd and 4th stages of DN can be avoided. Glomerular hyper-filtration and mesangial expansion are well-characterized manifestations of early DN, and due to this, microalbuminuria and increased GFR found in the early stage of nephropathy. This pathological concept is similar with Samprapti of Prameha which is characterized by Prabhutatva (~increased quantity of urine associated with or without increased frequency of micturition) and Avilatva (~turbid urine) may be due to hyper filtration and mesangial expansion.
The driving force behind the escalating prevalence of DN is obesity, hyperglycemia, and hypertension. Similarly, in Ayurveda food regimen which increases the quantity of Kapha and Meda in the body are said to be the causative factors of DN. Sedentary habits, increased consumption of sweets, fats, etc., may be considered as Nidana for DN. In this case, undiagnosed hyperglycemia might be the cause for its manifestation.
Description of some drugs having specific actions on Mutravaha srotas (~urinary system) is categorized under three categories. Mutra sangrahaniya (~urinary astringents) drugs having actions on Mutravaha srotas to regulate urine output; Muta virajaniya does the correction of urinary pigment disorders; and Mutra virechaniya Mahakasaya act as diuretics. Classics in Ayurveda advise to opt these Vargas (~group of drugs) by considering the involvement of Dosha and Dushya. Standard protocol has been designed based upon the concept of classics, research, and clinical outcomes. DN is considered as a disease of Mutravaha srotas. Protocol has guided that drugs of Mutravaha srotas having the properties of Kapha vata dosha shamaka, Ushna Veerya (~hot in potency), and Rasayana (~rejuvenating) are useful for the management of DN stages 1 and 2 and to improve the renal functions.
Gokshuradi guggulu is indicated for Prameha, Mutrakrichchhra, and Mutaghata. Gokshura has mentioned in Mutra virechaneeya gana and act as a Rasayana for Mutravaha srotas. It has anti-diabetic, anti-inflammatory properties. Due to Basti shodhana and Rasayana effect, it regulates the kidney function and help to maintain mesangial structures physiologically normal. With combination of Guggulu (~Commiphora mukul Hook ex Stocks), Triphala [Haritaki-Terminalia chebula Retz., Vibhitaki-Terminalia bellirica (Gaertn.)Roxb., Amalaki-Phyllanthus emblica Linn], and Trikatu [Sunthi-Zingiber officinale Rosc., Marich-Piper nigrum L., Pipli- Piper longum L.), it detoxifies the urinary system by balancing Tridosha and revitalized kidney. Studies reported that Triphala having hypoglycemic, antioxidant, anti-inflammatory, and immuno-modulating activities. Thus, administration of Gokshuradi guggulu helps to restore kidney function and correct leaking of microalbumin in urine.
Haritakyadi kwatha is indicated in the management of Mutrakrichchhra (~dysurea), Daha (~burning), and Ruja (~pain). It contains Haritaki, Duralabha (Fagonia cretica L.) Aragvadha (Cassia fistula Linn.) Gokshura (Tribulus terrestris L.)and Pashanbheda (Bergenia ligulata Wall.)In combination, it acts as Anulomaka (~smooth evacuation of Mutra) by normalizing the vitiation of Apana vayu, Mutrajanana, and Basti shodhana effect which help in proper formation of Mutra and correct the urinary abnormality. Research studies show that insulin release is nearly two times more in Haritaki treated animals and Methanolic, chloroform and aqueous extract of Haritaki is also reduced the blood sugar level in animal model. It has also renoprotective activity. Therefore, it is useful for the management of DN in combination.
Bhumyamalaki (Phyllanthus niruri L.)as mentioned as Mutrarogarti shamani and Daha nashini by Raj Nighantu. Because of Kshatapaha (~healing of tissue), Mutraroga nashini, and Rasayana qualities, it is helpful to repair disturbed renal tissues and prevent further injury by improving the nourishment of Mutravaha Srotas. Previous study reported that it contains tannins and flavonoids,both are active antioxidants and having the efficacy of regeneration of renal tubules. With Gokshura, it improves the resistance of renal tissues against any adversity.
Ayurveda classic advised to avoid Shaka varga in routine life, but these groups provide nutrition and help to eliminate disease by judicious use. The American Diabetic Association suggested the increased intake of nutrient-dense foods in appropriate quantity to improve overall health and prevent the risk of diabetes. Carbohydrate-rich foods, such as fruits, vegetables, having potassium, magnesium, and calcium, which modestly reduce blood pressure. The plant-based diet in the form of raw fruits and vegetables has the ability to reduce blood glucose levels both fasting and postprandial. Plant-based diet may be creating a favorable atmosphere in the body by maintaining Tridosha in the equilibrium and prevent further injury at the cellular level. In this study, it is observed that even after withdrawal of medicines, the plant-based diet helped to regulate kidney function. Before treatment, the value of microalbuminuria is 135.80 mg/24 h, and after one month, UAE decreased up to 40.70 mg/24 h, and after two months, it was reduced up to 23.10 mg/24 h.
| Conclusion|| |
Diabetic nephropathy is the leading cause of end-stage renal disease worldwide, and microalbuminuria is one of the initial predictor. The administration of Ayurvedapreparations with Pathya ahara used in this study is found effective in improving the kidney functions (microalbuminuria and eGFR). This study may bring a new hope to carry further research in the large sample size of DN for the prevention from overt nephropathy.
Declaration of patient consent
Authors certify that they have obtained patient consent form, where the patient/caregiver has given his/her consent for reporting the case along with the images and other clinical information in the journal. The patient/ caregiver understands that his/her name and initials will not be published and due efforts will be made to conceal his/her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Afkhami-Ardekani M, Modarresi M, Amirchaghmaghi E. Prevalence of microalbuminuria and its risk factors in type 2 diabetic patients. Indian J Nephrol 2008;18:112-7.
] [Full text]
Wang G, Ouyang J, Li S, wang H, Lian B, Liu Z, et al
., The analysis of risk factors for diabetic nephropathy progression and the construction of a prognostic database for chronic kidney diseases. Journal of Translational Medicine. 2019;17:264.
Jin Zhan G, Liu J, Qin X. Advances in early biomarkers of diabetic nephropathy. Rev Assoc Med Bras 2018;64:85-92.
Sastri R. Vidyotani. Hindi Commentary, Charaka Samhita of Agnivesh, Nidan Sthana. Prameha Nidan 4/6 Edition reprint 2015. Ch. 4. Charak Chaukhamba Orientalia; 2015. p. 632.
Sastri R. Vidyotani. Hindi Commentary, Charaka Samhita of Agnivesh, Nidan Sthana. Prameha Nidan 4/8 Edition reprint-2015. Ch. 4. Charak, Chaukhamba Orientalia; 2015. p. 633.
Sharma RK. Caraka Samhita of Agnivesh, Cikitsa Sthana; and Vaidya Bhagwan Dash. Vol. 1. Ch. 18/44,45,46. Varanasi: Chaukhamba Samskrit Samsthan; 2015.
Kumar A, Prajapati PK. Protocol for Management of Diabetes Mellitus and its Complications through Ayurveda. New Delhi: All India Institute of Ayurveda; 2017. p. 1-17.
Acharya YT. Charaka Samhita of Agnivesh, Sutra Sthan. 1st
ed., Ch. 25, Varanasi: Chaukhambha Surbharti Prakashan; 2014. p. 129.
Sharma H. Kashyap samhita, Khila sthana. Ch. 4., Ver. 6., Chaukhamba Sanskrit Sansthan Varanasi, Edition reprint 2015, p.378.
Tiwari PV. Kashyap Samhita, Amlapitta Chikitsa Adhyay. 1st
ed., Varansi: Chaukhamba Vishvabharti; 1996. p. 468.
Roy CB. Diabetes Reversal by Plant-Based Diet. J Metab Syndrome 2017;6:4,1-7.
World Health Organization. Global Status Report on Noncommunicable Diseases. Geneva, Switzerland: World Health Organization; 2014.
Srivastava SS, editor. Jivanprada Hindi Commentary, Sharngadhara Samhita, Madhyam khanda. Ch. 7. Ver. 84-87. 8th
edition. Varanasi: Chaukhamba Orientalia; 2016. p. 205.
Meena P, Anand A, Kumar VA comprehensive overview of Gokshura (Tribulus terestris linn.). JAIMS 2020;4:6,205-11.
Peterson CT, Denniston K, Chopra D. Therapeutic uses of triphala in ayurvedic medicine. J Alternat Complementary Med 2017;23:607-14.
Srivastava SS, editors. Jivanprada Hindi Commentary, Sharngadhara Samhita, Madhyam khanda. Ch 2. Ver. 103. 8th
edition. Varanasi: Chaukhamba Orientalia; 2016. p. 151.
Nalamolu RK, Nammi S. Antidiabetic and renoprotective effects of the chloroform extract of Terminalia chebula Retz. seeds in streptozotocin-induced diabetic rats. BMC Complementary Med Ther 2006;6:17.
Tripathi ID, Dravyaguna prakashiks Hindi Commentary, Raj Nighantu, Parpatadi Varga, Ver. 93, Edition Reprint. Varanasi: Chaukhamaba Krishnadas Academy; 2010. p. 123.
Bagalkotkar G, Sagineedu SR, Saad MS, Stanslas J. Phytochemical from Phyllanthus niruri linn. and their pharmacological properties: a review. Journal of Pharmacy and Pharmacology 2006,58:1559-70.
American Diabetes Association Standards of Medical care in diabetes-2015 abridged for primary care providers. Clin Diabetes 2015;33:97-111.
Lawrence JA, Thomas JM, Obarzanek E, William MV, Laura PS, Frank MS. et al
. A Clinical Trial of the Effects of Dietary Patterns on Blood Pressure. N
Engl J Med 1997; 336:1117-24.
[Table 1], [Table 2], [Table 3]