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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 14-19

Role of Ayurveda in the management of chronic kidney disease: A case study


1 Deputy Medical Superintendent, Hospital, All India Institute of Ayurveda, New Delhi, India
2 Department of Rasa Shastra & Bhaishajya Kalpana, All India Institute of Ayurveda, New Delhi, India

Date of Submission23-May-2019
Date of Acceptance08-May-2020
Date of Web Publication14-Jul-2020

Correspondence Address:
Dr. Alka (Babbar) Kapoor
All India Institute of Ayurveda, Sarita Vihar, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JACR.JACR_4_20

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  Abstract 


Wide emergence of chronic kidney disease (CKD) may be considered as a global threat, but with simple diet, lifestyle modification and early intervention, it can be managed through Ayurveda. It is possible to withhold morbidity and mortality, which occurs due to CKD. Currently, available conventional treatments for CKD have their own limitations. Considering those, alternate remedies for curing and curbing the disease progression are being worldwide welcomed. In Ayurveda, CKD may be compared with the subtypes of Mutraghata (~obstructive and suppressive uropathies), for which extensive treatment modalities have been described in classics. In the present study, 37-year-old female patient diagnosed with Stage-3 CKD (estimated through either glomerular filtration rate) visited the outpatient department complaining headache, restlessness, shortness of breath, swelling in feet, tiredness, etc. She had a history of anemia and blood transfusion every 6 months for 18 months, for which she was investigated and later diagnosed as a case of CKD. Initially, she was prescribed with Trina panchamoola kwatha, Punarnava mandoora, Syrup Neeri KFT, and Kamadudha rasa for two months, and further treatment was altered and tailored according to the patient's condition and Shatavari, Shivagutika, Punarnava mandoora, Lauhasava, Chandanasava, Varunadi kwatha, and Gokshura churna were prescribed in the different phases of management. The patient was advised to avoid milk and milk products, vegetables such as cabbage, spinach, brinjal, and avoid the suppression of naturalurges. Increase in hemoglobin level (to 10.2 mg/dl) and decrease in creatinine level (to 0.9 mg/dl) were observed. The patient did not have to take blood transfusion either. The case clearly reveals the significance of ayurveda treatment modality in the management of CKD.

Keywords: Ayurveda, chronic kidney disease, Mutraghata


How to cite this article:
Kapoor A, Dang PG. Role of Ayurveda in the management of chronic kidney disease: A case study. J Ayurveda Case Rep 2020;3:14-9

How to cite this URL:
Kapoor A, Dang PG. Role of Ayurveda in the management of chronic kidney disease: A case study. J Ayurveda Case Rep [serial online] 2020 [cited 2020 Sep 19];3:14-9. Available from: http://www.ayucare.org/text.asp?2020/3/1/14/289375



[TAG:2]Introduction[/TAG:2]

Chronic kidney disease (CKD), falling under the umbrella of noncommunicable diseases is emerging as a global threat, reducing the productive years, life expectancy,[1] causing immense health expenditure, and increased socioeconomic burden, thus dilapidating an individual as well as society.[2],[3],[4] CKD is characterized with disrupted kidney function for more than 3 months or in other words, it may be defined as the kidney condition with glomerular filtration rate (GFR) <60 mL/min per 1.73 m2, raised biomarkers (i.e., albuminuria, urine sediment abnormalities, electrolyte imbalance, histological abnormalities, structural abnormalities, and kidney transplant histories).[5] Diabetes and hypertension constitute the major risk factors of CKD. It is often left unnoticed at the early stages and generally diagnosed at later stages as the patient remains asymptomatic for long time or have nonspecific signs and symptoms such as lethargy, loss of appetite, and itching etc.[6] Confirmed diagnosis is made after the routine investigations of urine and blood, i.e., proteinuria, serum creatinine levels, GFR, etc. Proteinuria is often indicative as the risk of disease progression and death. Kidney biopsy further provides the definitive evidence of CKD, depicting changes in tubes, etc. Reduced kidney function is seen in CKD, but over the period of time, disease manifestation occurs in five stages and is finally seen as the end-stage renal disease.[7]

Ancient seers include four types of Ashmari (~calculi and urinary lithiasis), 13 types of Mutraghata (~obstructive and suppressive uropathies), eight types of Mutrakrichha (~dysuria), and 20 types of Prameha (~metabolic disease) in Mutravikara (~disorders of urinary system). Among the 12 types of Mutraghata described by Acharya Sushruta,[8] CKD may be comparable to Mutrakshaya, Mutrasada. Acharya Sushruta opines that Mutrakshaya occurs in Ruksha and Klanta (~rough and exhausted) person, when vitiated Pitta and Vata (~bodily humour) located in the urinary bladder causes decreased urine production with burning sensation and pain.[9] On the contrary, Mutrasada manifestation occurs due to Pitta or Kapha vitiation in the bladder leading to yellow color with burning or white slimy urine production.[10]

Patients of CKD have to undergo treatment modalities such as dialysis, kidney transplantation that are not easily affordable to all. Hence, there is a need to establish affordable medical care. Various Kwatha (~decoctions), Ghrita (~clarified butter), Ahara, asava (~edibles, and wines,), etc., are prescribed in classics. In all types of urine disorders, Vata dosha is the prime causative factor collaborating with Pitta and Kapha. Hence, general treatment is applied considering Doshas, drug and disease.[11]

[TAG:2]Case Report[/TAG:2]

A 37-year-old female patient reported at the outpatient department in May 2016 complaining of headache, restlessness, fatigue, low hemoglobin levels, swelling in feet, and shortness of breath on exertion for 18 months. Her ultrasonography findings were suggestive of moderate splenomegaly and renal disease (bilateral kidneys depicted raised renal cortical echo texture with partial loss of cortico-medullary differentiation). The patient did not have any problem till 2013, then she gradually developed anemia. She took allopathic treatment, oral iron, and calcium tablets and underwent blood transfusions every 6 months for the same. In September 2015, allopathic doctor diagnosed her condition as CKD with elevated blood urea nitrogen (74 mg/dl) and serum creatinine levels (3.2 mg/dl). The patient had Vatapitta prakruti, was nonhypertensive, nondiabetic, and had no alcoholic or narcotic addiction, did not have any family history for any other ailments. She was anemic for 3 years. She was of average nutritional status, bowel and bladder were normal, whereas sleep and appetite were reduced.

Clinical findings

On general examination, the patient was wheatish complexion medium built female. Blood pressure was 118/87 mmHg and pulse was 107/min. She had massive pallor and pedal edema. On the examination of bulbar conjunctiva, the icterus was absent. Central cyanosis, digital clubbing, and cervical and mandibular lymphadenopathy were absent. On systemic examination, no circulatory, respiratory, and digestive abnormality were noticed. Per abdominal examination did not reveal anything significant.

Dashavidha pareeksha (~Ten fold examination)

Prakruti (~body temperament) was Vata pitta; Vikriti was Vata pradhana tridoshaja; Satva (~psyche) was Madhyama (~moderate); Sara (~excellence of tissues), Samhanana (~compactness of organs), Aahara shakti (~power of food intake), Satmya (~suitability), Pramana (~measurement of body organs) were Madhyama (~moderate). Vyayama Shakti (~power of performing exercise) was Heena (~poor).

Ashtavidhapareeksha (~Eight fold examination)

Nadi (~pulse) was Vataja; Mala (~bowel) was Vibhadda (~constipated) and irregular; Mutra (~urine) was Alpa and Phenila (~less in amount and frothy); Shabda (~voice) was Sadharana (~normal); Jihva (~tongue) was Svachha (~clean) and pale; Akriti (~body built) was Madhyama (~moderate); Drik (~vision) was Heena (~diminished).

Strotas pareeksha

The channels of circulation carry Dhatus (~tissue elements) undergoing transformation to their destination.[12] The origin site of circulation channels for urine are bladder and kidneys. The characteristic manifestations of vitiation of these channels are voiding of too much urine or complete supresssion of urine and occasionally or frequently passing of thick urine associated with pain.[13]Sanga (~complete or partial obstruction of Srotas) and Vimarga gamana (~leaving its own channel and enters in other channel) in Mutravaha strotas (~urinary system) are involved in pathology.

Diagnostic assessment

It was done with the help of blood examination, i.e., hemoglobin, serum urea, creatinine, uric acid, and electrolytes [Graph 1].



[TAG:2]Treatment Protocol[/TAG:2]

After thorough examination of the patient, the treatment was started with 10 g of Trina panchamoola kwatha churna,[14] 250 mg of Punarnava mandoor,[15] 2 Tsf (table spoon) of Syrup Neeri KFT, and 125 mg of Kamadudha rasa in BD (twice a day) doses. After 2 months, the treatment was revised and 10 ml Chandanasava,[16] 10 ml of Lauhasava,[17] 3 g of Shatavari churna, and 3 tea spoonful of Punarnava arka[18] in BD doses were prescribed. This treatment was continued for a month, thereafter, the patient was advised 20 ml of Varunadi kwatha, 10 ml of Punarnava kwatha,[19] 2 g of Gokshru churna, 1 g of Shatavari churna, 125 mg of Shiva gutika,[20] and 250 mg of Punarnava mandoor in BD doses [Table 1]. Apart from this, the patient advised to avoid milk and milk products, vegetables such as cabbage, spinach, brinjal, preserved food items, trans fats, and saturated fats such as vanaspati ghee, avoidance of foods rich in minerals, and avoidance of suppression of natural urges. Addition of starchy and roughage rich (draining away water) diet was advised.
Table 1: Treatment protocol

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[TAG:2]Followup and Outcome[/TAG:2]

There was the improvement in headache, restlessness, fatigue, pedal edema, dyspnea on exertion, and appetite. There was a gradual increase in hemoglobin level from 6.4 to 10.2 mg/dl, while decrease observed in creatinine level from 3.2 to 0.9 mg/dl, uric acid level from 7.6 to 4.2 mg/dl, and blood urea level from 74 mg/dl to 32 mg/dl. Electrolytes, i.e., serum sodium and potassium levels were altered initially in 2015, and then, were within the normal range throughout the course of treatment [Graph 1].

[TAG:2]Discussion[/TAG:2]

To treat CKD on Ayurvedic principles, it is necessary to identify the nature of disease in terms of its component Dosha (~humour), Dushya (~part which is affected), and Adhishtana (~abode). In CKD, impairement of renal function is brought about by the derangement of Tridoshas (~three humours; Vata, Pitta, and Kapha), with predominance of Vata dosha, Agnimandya (~weak digestive fire), Srotosanga (~obstruction in microchannels of Mutravaha srotas), and Vimarga gamana. It is essential to break the pathogenesis to get the desired results. Thus, the treatment of CKD aims at the enhancement of digestive fire, balancing vitiated Doshas, diuresis and control of excessive salt and water retention, Sroto shuddhi and Rasayana chikitsa; which may create an improved nutritional status by acting on levels of Rasa, Agni, and Srotas. In view of above line of treatment, the treatment of the present case was started.

The patient was a diagnosed case of CKD, with elevated serum urea, uric acid, creatinine level with reduced hemoglobin level, and very often undergo blood transfusion. Urea is nitrogenous end product produced from protein and aminoacid catabolism, thereby excreted by the kidneys. The elevated levels are indicative of kidney hypofunction.[21] Serum creatinine is a waste product produced as a result of muscle activity and removed by the kidney. Therefore, elevated level observed in renal disease.[22] Similarly, uric acid level, being end product of purine metabolism is elevated due to purine rich food intake. Higher uric acid level is associated with rapid decrease in glomerular filteration rate and increasing risk of kidney failure.[23] Anemia is presented as major complications in CKD. In CKD, reduced production of intrinsic factor, i.e., erythropoietin by kidneys (due to destructed renal parenchyma), reduced red blood cells (due to uremic toxin and decreased RBC lifespan), and iron deficiency occurs. Decreased erythropoiesis leads to bone marrow space fibrosis and decreased platelet count, thereby increasing the bleeding tendency while further lowering blood volume and hemoglobin levels.

Initially, for 2 months, the patient was advised Trina panchamoola kwatha, Punarnava mandoora, Neeri KFT, and Kamadudha rasa. The patient was administered Trina panchamoola kwatha due to its Vata pitta shamaka, diuretic, kidney stimulant, and hemopoetic properties.[23] The ingredients of Trina panchamoola are mentioned in Mutra virechniya dashemani. These are used for the treatment of asthma, anemia, and possess diuretic properties.[24]In vitro studies indicate its free radical-scavenging activity,thereby bears potential to treat ailments in which free radicals are produced.[24]Punarnava mandoora was administered due to its Agnivardhana, Panduhara, and Rasayana properties.[25]Mandoora bhasma (~incinerated form of iron-Fe2O3), the main active ingredient is responsible for depicting pharmacodynamic action of Punarnava mandoor. By the virtue of Rasa, Guna it is Pitta pacifying, thereby maintaining normalcy, improving digestion and metabolism. Hence, Acharya Charaka advocates, Mandoora and its compounds vital in treating Pandu (~anemia).[26] Mandoor's ferric and ferrous fractions provides iron to the living beings in sufficient amounts needed for normal erythropoiesis.[26] It also alleviates edema. Neeri KFT being nephroprotective and anti-inflamatory ingredients has been prescribed.[27] CKD involves the Mutravaha srotas primarily involving Vata vitiation, further causing degeneration of kidney tissue and structure. Rasayana drugs possess special tissue healing capabilities, thereby improving tissue qualities and increased resistance to structural damage.[28]Kamadudha rasa is medicine-soothing urinary system, pacifies Pitta dosha and exerts mild diuretic effect.[29]

Despite continuing the medicines for 2 months, the patient's hemoglobin level was still low and serum creatinine and blood urea levels raised, therefore, few medicines were added, i.e., Shatavari churna (~ powder of Asparagus racemosus L.), Punarnava arka (~distillate of Boerhavia diffusa L.), Chandanasava (~Asava of Santalum album L.), and Lauhasava. Punarnava, Shatavari have deipcted par excellence in the diseases of Mutravaha srotas by virtue of their Rasayana action, hence, included in the treatment.[30] Not only Shatavari is a rejuvenating herb,[31] but also adds on to the nutrient value.In vivo studies have proved that Shatavari decreases the serum creatinine level.[32]Chandanasava is Pitta shamaka (~pacifying Pitta), Sheeta virya (~cold potency), and has healing properties of urinary tract. Lauhasava, works in augmenting hemoglobin percentile, improving liver function, Agni, reconciles digestive system, thereby curing anemia. Thereafter a month, the patient's blood reports were evaluated, i.e., hemoglobin levels, serum creatinine, and blood urea serum electrolytes. Hemoglobin level continued to be low; hence, Punarnava mandoora was continued. Serum creatinine level was persistently high (3.1 mg/dl) so Gokshura (Tribulus terrestris L.) was added owing to Rasayana action and decreasing serum creatinine levels.[33]Shatavari churna continued due to its serum creatinine-lowering effect. Varunadi kwatha (~decoction of Crateva nurvala Buch.),[34]Shunthi (Zingiber officinale var.), Gokshuru (Tribulus terrestris L.), and Pashanabheda (Bergenia ligulata Engl.) were also helpful to relieve the Kapha and Vata doshas and having excellent diuretic properties.

On evaluating serum electrolytes, electrolyte imbalance was observed. Keeping this view in mind, Shivagutika was administered for some time, seeking normal electrolyte levels, it was then withdrawn. Main ingredient of Shivagutika is Shilajatu (~asphaltum). It is having Kashaya (~astringent) and Tikta rasa (~bitter taste), Sheeta virya (~cold potency), Tridosha hara (~pacifying three doshas), Vrishya (~approdisiac), Balya (~strengthening), Mutrala (~diuretic), Lekhana (~scraping), Yogavahi (~spreading to microchannels), Rasayana (~rejuvenating) and is used in the treatment of anemia and swelling.[35]Shilajatu is composed of humic substances and fulvic acid which is having strong antioxidant property and its complement-fixing activity accounts for its curative properties.[36],[37],[38] This same treatment was continued for further six months, and blood investigations were observed within the normal range.

[TAG:2]Conclusion[/TAG:2]

Mutraghata stands for the suppression of urine output. The disorder of Mutravaha srotas has resemblance with the description of urological disorders of modern parlance. On the basis of history and clinical presentation, the patient was diagnosed as case of CKD, it's treatment with Ayurveda was found encouraging. Significant increase in hemoglobin levels and decrease in serum creatinine, blood urea, and uric acid levels were seen. Hence, timely health checkups, screening, with early intervention may retard the disease progression. Preventive health strategies, i.e., educating about disease and lifestyle interventions will further help.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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