Journal of Kidney

Management of Chronic Renal Failure (CRF) through Ayurveda-A Case Report

Punam Sawarkar^1* and Gaurav Sawarkar^{2 *}Correspondence: Punam Sawarkar, Department of Panchakarma, Mahatma Gandhi Ayurved College Hospital and Research Centre, Salod, Wardha, Maharashtra, India, Email:

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Introduction

Chronic kidney disease (CKD) is a clinical condition where hampering of kidney function progressively takes place over months or years. If not treated at an early stage or ignored at the primary level, it can convert into some life-threatening conditions. Many developing countries have a high prevalence of CKD. The occurrence of the prevalence of CKD in India varies from 0.79% to 1.4%, and the incidence rate of its conversion into end-stage kidney disease was estimated to be 181 per million population in 2005 [1]. It most common entity which generally occurs in persons having age between 40 -60 years. Factors such as age, sex, hypertension, diabetes, athereosceloris, overuse of painkillers, Obesity hyperuricemia, area of residence, and economic status have a strong positive independent correlation with progressive CKD [2]. Among them, prolonged hypertension and consumption of analgesic medicines are the most contributing factors for developing CKD [3], which induces damage to nephrons and renal parenchyma, resulting in decreased blood filtration capacity of the kidney. Due to the current era of modernization, all the above causative pathologies in the form of lifestyle disorders are flourishing day by day, which may become favorable conditions for developing CKD.

CKD has five stages of clinical manifestations with deterioration in renal function in successive order. Primary pathology involved in this disease is glomerulonephritis, or chronic kidney infections which diminishes the capacity of renal tissue to filter the blood & metabolic toxins doesn't get eliminated from blood and get saturated in the blood which yield impaired & higher levels of serum blood urea as well as serum creatinine with some specific clinical features such as the decreased output of urine, Hematuria or proteinuria (especially albuminuria) and swelling over the body (pitting edema) which occurs due to obstructions of channels in blood circulation as a result of stagnation of harmful substance like Urea. This condition is generally presented with mild impairment in biochemical parameters, including renal profile initially followed by specific clinical features or vice versa also. Identification & treatment of underlying causes are generally applied to achieve restoration of kidney function & to check the process of converting disease into end-stage. Treatment at the primary level in this disease becomes mandatory. It is a very frustrating disease in advanced stage due to its non-responding nature even to dialysis, which is quite expensive therapy in such conditions. Previous various case studies show that there are increasing chances of developing complications in the form of bleeding, infection, vascular thrombosis, and transplant rejection due to dialysis and renal transplantation, which are conventional measures of CKD management. In addition to these, both interventions are quite cost expensive. Considering all the scenarios mentioned above, an hour is needed to search for some alternative, cost-effective & safe therapy in alternative medicine for the management of CKD.

In Ayurveda, CKD can be correlated various 13 conditions of Motraghata which are Tridoshaja in nature and where the formation of urine get hampered due to intrinsic as well as some extrinsic factors e.g., Suppression of Mala, Mutra, Apan Vayu & Shukra, Ruksha Padartha Sevana & Tikshna Aushadha & Annapana which are narrated under term Mootravaha strotodushti Hetu. Among them, factors affecting Medovaha Strotas e,g. obesity is also responsible for that which is supported by modern science even [4-6].

The term Mootraghata is known as obstruction in urination or defect in the formation of urine. Arrival of Vata Prakopa occurred due to those as mentioned above, external and internal causative factors in the Basti region, which is the primary location for Samprapti of Mootraghata. By taking into consideration, the relation of CKD with Mootraghata due to similarity in symptoms and a review of Mootraghata with its different causative pathologies, Sthoulyahara(anti-obesity), Mootrala or Mootraghatahara or Chikitsa in Shotha Vyadhi are generally preferred for CKD.

The present case study is an excellent example of a safe & effective alternative approach of CKD management with Ayurvedic principles.

Patient information

68-years old male patient was clinically diagnosed as a CKD case with HTN presented with following chief complaints for 5-6 years. It was associated with stiffness and pain in the lumbar region, distension of abdomen, loss of appetite and constipation, pallor, lassitude, and difficulty in doing his normal day-to-day activities walking, sitting, squatting, and taking a bath independently (Table 1).

Table 1: Nature of chief complaints.

Progression of disease

The patient was suffering from lumbar spondylitis & obesity for 30-35 years. Due to severe low backache, he used to take analgesic from counter prescription weekly thrice. He was diagnosed with HTN at the age of 20 years. So, he was prescribed antihypertensive medicine from age 20 years by a general physician, and it was going on to date. But before 5-6 years, he was recurrently suffered from specific complaints such as swelling all over the body, including puffiness of face, distension in abdomen, bipedal edema, and hesitancy while micturition, recurrent UTI with persistently raised both systolic as well as diastolic bold pressure & headache. .So his relatives consulted with the cardiologist at Yavatamal, and he advised some routine investigations such as USG Abdomen with pelvis &liver, kidney & lipid profile. Among them, lipid & liver profile was healthy. Still, USG Abdomen with pelvis shows a small hyperechoic kidney that suggests chronic medical disease. There were high values of serum creatinine & serum blood urea, which was persistent high than the normal range till Ayurveda intervention. So the cardiologist started appropriate treatment to him, including Tab soda mint with strict prohibition of concomitant analgesic medicine. But despite taking this treatment for five years continuously, there were many fluctuations in renal profile & persistent status of clinical features. So, after six years, he approached to Ayurveda medicine with his relatives.

Family history: History of hereditary obesity in parents & Siblings. Father known case of IHD & HTN

History

1. Patient was known evidence of HTN from the age of his 20 years

2. Obesity for more than 45 years

3. Lumbar spondylosis due to degenerative changes in lumber spines since 30-35 years

4. Chronic constipation since 30 -35 years

5. Hyperureimia since five years

6. Recurrent UTI since 2-3 years

Personal history

Diet history: Craving for non-vegetarian diet (weekly 5-6 times).

Lifestyle style: Sedentary lifestyle due to his business with the daily habit of Diwaswapa.

Bowel habit: Irregular & unsatisfactory bowel habits.

Drug history

1. The patient had taken analgesics for 30-35 years for lumbar pain (approximate weekly thrice). He was advised to restrict the use of analgesic& fruit intake after his diagnosis as CKD.

2. Antihypertensive medicine: Tab Prolomet 5/50 mg 1 OD &Tab Prozppress 15 mg 1 od since 49 years

3. Tab Sodamint 1 tab bd since five years

Addiction history

Not specific

Clinical findings

Local examination: On the day of the primary assessment, there was swelling all over the body, bipedal edema & puffiness over the face. The patient couldn't stand or walk without support & he was brought in a wheelchair. SLRT was positive on both sides at 35 degrees with sciatic notch tenderness on both sides. Abdomen was distended but without everted umbilicus.

Ashtavidha pariksha: Nadi –Vatakaphaja

Mala-Grathit, (Hard &unsatisfactory    

Mootra – Shania shnanei, Sadaha (Frequent burning micturition with &unsatisfactory feeling of complete evacuation of bladder)

Jivha – Alpasaama

Druk - Spashta

Shabda - Karkash

Akruti - Sthoola

General examinations  

1. Weight -113 kg (at the time of primary assessment)
2. B.P.-160/100 mm/Hg ( in supine position at the time of primary assessment)
3. RS – Pulse:-84/min
4. Clear
5. CVS-S1S2 Normal

Diagnostic assessment

The patient's diagnosis was made as CKD with HTN & Cervical Spondylosis (Moootraghata with Gridhasi) with the help of a history of complaints, medication, clinical signs & symptoms as well as previous reports of biochemical tests & USG findings (Table 2).

Table 2: Diagnostic assessment.

Therapeutic intervention

Treatment planned & given in this patient is mentioned in (Table 3).

Table 3: Treatment given.

Observation And Results

After the successful intervention of the treatment as mentioned earlier regime consecutive for one month, there was a significant reduction in weight as well as a considerable improvement in clinical features such as absence of puffiness of face & bipedal edema. There was no hesitancy during micturition with a lack of burning sensation in urine, relief in constipation, improvement in appetite, absence of lassitude, and aid in low backache with loss of stiffness in the lumbar region. In biochemical parameters, there was a significant reduction in serum creatinine (from 4.89 to 1.81 in 1 month) as well as blood urea (from 64 to 50mg /dl) with a decrease in the percentage of urine albumin. In addition to above findings, there was one interesting finding that blood pressure of that patient came to normal range i.e., 130/90 mm/Hg after one month of intervention which was persistently at higher range (above than 160/100 mm/hg) despite taking his routine Antihypertensive drug in contemporary science (Table 4 &5).

Table 4: Assessment of clinical features.

Discussion

Discussion on disease

This is the typical case of Santarpanyajanya Vyadhi & complication of Dooshivisha, taken in the form of analgesic for long duration leading to the generation of Mootraghata. There are a total of 13 types of Mootraghata narrated in various Ayurveda compendiums. Among them, this patient had combined symptoms of Mootrasada (due to burning micturition), Mootra Jathara (distension below umbilicus & all over the abdomen, indigestion, retention of urine & Stool), Mootratsanga (some urine is obstructed & after some time it get micturate with or without pain due to vitiation of Vata or Kha Vaigunya) & Mootrakshaya (scanty urination). There was vitiation of mainly Vata & Kapha Dosha in the pathogenesis of all the above clinical conditions. Therefore, mainly Vata-Kaphahara treatment was applied in this patient.

Main important causative factors or Hetu e.g., Santarpanajnya & Abhishayndi Ahara(daily Non-veg diet), Vihara (chronic constipation, daily habit of Diwaswapa which is considered as one of Medovaha Strotodushti Hetu, sedentary profession), the lengthy history of HTN since 49 years which is the one of primary cause along with DM for development of CRF [7] & long term consumption of analgesic for consecutive 30 -35 years (which is nephrotoxic) cumulatively induced Stotovaigunya in Basti Pradesh & Vitiation of Kapha as well as obstruction in channels of Vata in this patient and kidney damage with the destruction of renal tissue was carried out. In this patient, HTN, since prolonged duration, plays a crucial role in the pathogenesis of CRF by inducing parenchymal damage within the kidney and a provocation of further deterioration of kidney function [8]. The second contributing factor in this patient is the intake of Analgesics (Tab.combiflame), and non-steroidal anti-inflammatory drugs, which is the most cause induces Kidney papillary necrosis and chronic interstitial nephritis converting into progressive Kidney failure [9,10].

All the above factors lead to Kapha Prakopa & hampers Vayu's normal Gati or movement, especially Apanavayu. It had resulted in the disturbance in the elimination of Mala. Mootra & flatus leads into the development of clinical features of Mootraghata e.g., hesitancy while micturition, distention in abdomen, swelling all over body, etc. Due to improper/incomplete evacuation of Mootra from the urinary bladder, there was the stagnation of turbid urine, which leads to favorable conditions for the growth of microorganisms such as E. Coli, resulting in recurrent UTI in this case.

Discussion on treatment

All the above causative factors & specific pathology induced by them were taken into consideration while treating this patient. Though all the Tridoshas have importance in the pathogenesis of CRF, Kapha is highly responsible for obstruction of microvessels in kidney & Vata Dosha chiefly induces degeneration of the structure of the kidney which ultimately cumulatively lead to progressive CRF. Therefore, drugs having properties of Lekhana, Mootrala & Rasayana are selected here for treatment of CKD to repair previously damaged tissue & to avoid further damage since all drugs involved in the given treatment regime have abilities to remove blockages & to improve qualities of fabrics due to their scrapping effect. Lekhana Properties of all medicines are required to treat this patient since CKD is a Mootra Dosh Vikar, and both Kidney i.e., Vrukka described in Samhita, which is the root of Medovaha Srotas, so ultimately Meda Pachana Chikitsa is expected here. History of obesity & current weight gain in this patient was one of another reason to adopt such type of treatment [11].

Local Snehana (from lumbar region to both lower limbs) & local Nadi Swedana-Induces improvement in blood circulation & remove waste material from that region. It decreases swelling in local tissue& acts as an excellent muscle relaxant. It accentuates the effect of Niruha Vasti, which was administered latter. Vata-Pacifying, analgesic & anti-inflammatory effect of local Snehana & Nadi Swedana is explained by Sawarkar et al. .2018 [12].

Sasneha Niruha Vasti-As Niruha Basti is considered a minor alternative to dialysis in CRF as per Manish V. Patel et al. (2011) [13]. All drugs, including decoction of Dashmool+Triphala+Punaranava+Musta+Ashwagandha with Honey, Saindhava, Sahachara Oil & Avapa with Gomutra were utilized in Niruha Vasti which is Lekhana & Vatakaphaghna in nature & this type of Vasti is useful in Santarpanyajanya Vyadhi. It induces Vatanulomana, especially Apanavayu, due to its Vataghana, Shothahara & Mootrala effect.

Medicines used for Dashamooladi Niruha Vasti i.e., Dashmoola, Triphala, Guduchi & Punaranava, and Musta exhibit antioxidants anti-inflammatory and detoxification activities due to their Rasayana, Tridoshahara and Amapachaka properties which help to rejuvenate damaged capillaries, removal of atherosclerosis, improve blood circulation and GFR. It is a type of Tikshana Vasti, which induces irritant effect due to its high potency, which is increased by Avapa of Kshara i.e., Gomutra. While Sahachara oil used in Niruha Vasti as Sneha not only removes obstruction but also increases blood circulation to that region due to its Vata –Kaphahahara properties [14].

Kamdhenu Gomutra Ark: According to Ayurvedic Samhita, Gomutra is termed as Ushana, Tikshna, Kapaha Medaghana Lekhana, Mootrala, Karshana, and Vishaghna, specially indicated in Kapha & Meda vitiated Sanatarapanajunya conditions. Deepaka, Pachaka, Srothovivarana properties of Gomutra is also explained based on its features by Sawarkar et al. (2018) [15]. As it has above different properties it was prescribed for oral use in Shamana quantity (15 ml BD, with warm 50 ml water), empty stomach in morning and evening in the evening as well as in Niruha Vasti in this case. In this case, it becomes helpful due to its Vishahara(detoxification) property to eliminate the residual toxic effects of prolonged consumption of analgesics. It’s bio-enhancing, antioxidant; immuno-modulator, apoptosis & antimicrobial activity became helpful in CRF.

Chandraprabha Vati-Due to its Mootrala & Shotahhara properties, it smoothly induces Anulomana of Apanavayu. It reduces symptoms of UTI with its Shothaahra & antibacterial property. It produces Rasayana effect over Mootravaha Srotas due to its Kledahara Property. Due to its Lekhana property, it cures vitiation of Kapha and Vata Doshas [16].

Syp Neeri KFT –Proprietary medicine by Aimil Pharma helps increase glomerular filtration rate and creatine clearance due to its properties of nephrotonic, Antioxidant & immunomodulation in CRF. Nephroprotective role of Neeri-KFT is proved by Anil et al, [17]. It protects the kidney naturally with scientifically proven herbs such as Boerhaavia diffusa, Tinospora cordifolia, Nelumbo nucifera, Butea monosperma, Tribulus terrestris, Moringa oleifera, Veteveria zizanioides, Crataeva nurvala, Amaranthus spinosus, etc. along with some classical Ayurvedic formulations like Panchtrinmoola used in its preparation.

Gandharva Haritaki powder-Mrudu & Snigdha Anulomaka nature of Gandharva Haritaki powder induces smooth & regular Stool elimination without causing Vata's vitiation. Nitya Virechana, with Gandharva Haritaki, is the best remedy to resolve constipation in disease having the involvement of the Apanava Vayu & Lumber region (Kati Pradesh), which is the leading site of Apan Vayu. The use of such type of Mrudu Virechana is recommended in Vata predominant disorders and diseases situated in central locations of Vata Dosha.

Rasnasaptaka Qwath-Vata Kapahahara nature of Rasnasaptaka Qwath reduces symptoms of Katigata Vata & relives stiffness & pain in Gridhasi with its Vata Shamaka & Dipana property.

Punarnavadi Qwath –Induces Shothahara action by potentiating Mootral effect. Punanava, Guduchi, Gokshura in Punaranavadi Qwath has Rasayana effect. This effect improves the Jatharagni & functional capacity of patients. It increases glomerular filtration rate due to its neuroprotective nature.

Tab Shallaki XT-Proprietary medicine by Guffic pharmacy, which is excellent muscle relaxant in nature & reduces symptoms of Gridhasi due to Vata Kaphahara Property of Nirgundi &Shallaki, which are the main ingredients of this medicine. The role of Tab shallaki XT in the musculoskeletal entity is very well elaborated by Punam Sawarkar et al, [15-18].

Significant reduction in Serum blood urea & serum creatinine was observed in this patient may be due to diuretic action of Chandraprabha Vati & Punaranavadi Qwath. Tikta Rasa of Punaravadi Qwath and Rooksha-Tikshana Guna of Shodhana Vasti help to digest Ama, induces Stotoshodhana effect by removing vitiation of Rasa Dhatu. After intervention, a significant reduction in serum creatinine indicates improvement in glomerular filtration rate and the increased capability of the kidneys to eliminate waste products through urine. Significant results are induced in this case due to the cumulative action of All the drugs mentioned above, including Dashamooladi Niruha Vasti, by their properties such as Strotoshodhanaka, Kledanashana, Mootrala, Vata –Kaphahara, Rasayana as well as effects such as counter-irritant, antioxidant & rejuvenation.

Conclusion

The present case study is a good example showing dreadful impacts of faulty lifestyle & consumption of counter medicine without prescription & consultation with physician. Due to rational approach of Ayurveda treatment applied in such patient by using basic principles of Ayurveda & by taking pathology in relations with its causative factors into consideration, it clears that Ayurveda can efficiently manage such condition with similar symptoms in the early stage of disease without causing any undue effect with multiple secondary benefits also. The progression of disease into a further phase can be prevented in such patients to avoid interventions in advanced stages such as dialysis & to avoid financial burden over society. Further & extensive research is needed with a similar response in a large sample size to establish its utility in CRF. Simultaneously, exploring various causative factors with their specific pathologies in the same clinical conditions should be done on a priority basis to yield the maximum benefits of such therapy. This case study may become a ray of hope for the patient having CRF.

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