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TITLE OF CASE

Ayurvedic standalone management of Microalbuminuria in Type II DM - a case report

Dr Indu

ABSTRACT

A 64-year-old female patient was a known diabetic for 14 years and had hypertension for 5 years. She is on allopathic medication for diabetes and hypertension. She complains of frothiness of urine and bilateral ankle swelling for 6 months. She did not consult any allopath for this specific symptom. She consulted Dr Indu for Ayurvedic management. Based on the lab investigations, the biomedical diagnosis was made as Microalbuminuria in Diabetes Mellitus. Based on the clinical evaluation, the ayurvedic diagnosis was made as Prameha janya abhyantara vidradhi pidaka. The line of treatment followed was prameha hara. With one month of Ayurvedic treatment, the 24 hour Microalbumin level – 100 mg/day at baseline became 30 at endpoint level reached within normal limits and the patient got relief from all the symptoms. This case report highlights the clinical efficacy of ayurveda in treating Micro albuminuria using a simple single formulation.

KEYWORDS

Microalbuminuria, diabetic mellitus, madhumeha, case report, vidradhi, pidaka, abhyantara vidradhi pidaka

INTRODUCTION

Albuminuria means you have too much albumin in your urine. It is a sign of more significant kidney disease. Microalbuminuria is when a small amount of protein called albumin is present in your urine. Microalbuminuria indicates that your kidneys aren’t functioning optimally and can sometimes be a sign of kidney disease. It also is a risk factor for cardiovascular disease.

Cause: Microalbuminuria is caused by kidney damage. Some medical conditions that can lead to kidney damage include:

• High blood pressure: People who have high blood pressure for a long time often have microalbuminuria. In these people, the condition is often also associated with other cardiovascular problems.
• Metabolic syndrome: Microalbuminuria is also associated with metabolic syndrome, a cluster of conditions that increase your risk of developing heart disease, diabetes, and other chronic health conditions. 
• Type I and type II diabetes: People with diabetes may develop scarring and thickening of the nephrons, which are the filters that help remove waste products from the blood. This can lead to poor kidney function and albumin leaking into the urine.
• Obesity: Obesity can cause damage to the structure of the kidneys, affecting their function and leading to microalbuminuria. Obesity is also associated with other risk factors for kidney disease such as diabetes and hypertension.
• Genetic kidney diseases: Microalbuminuria is often present in people with inherited kidney conditions such as polycystic kidney disease.

Symptoms: Usually, microalbuminuria does not cause any symptoms. It can, however, be one of the earliest ways to detect kidney disease.2 Kidney damage may become significant (and not easily reversed) before a person notices any symptoms. This is part of why it is important for people at risk of kidney disease to have the test repeatedly so that treatment can begin if necessary.

If microalbuminuria goes undiagnosed, your albumin levels will continue to rise. One of the symptoms you might notice when this happens is foamy urine. Kidney damage can also cause swelling of the hands, ankles, face, or abdomen.

Diagnostic Criteria: Microalbuminuria is diagnosed based on laboratory urine tests that might be performed along with a standard medical exam. 

Prognosis & Treatment: Different treatments are available to address microalbuminuria. The best treatments may depend on the underlying causes, other medical conditions, and factors like your age and sex. In general, if you have medical conditions that may be worsening your kidney function (like diabetes), it’s helpful to get those under better control.

PATIENT INFORMATION

The patient is a 64 year old female patient, who is a known case of Diabetes mellitus since 14 years, complains of frothiness of urine and bilateral ankle swelling since 6 months. She had not taken any prior treatment for this condition. 

Family History- Positive family history of DM2- father, mother, and siblings

No relevant genetic/surgical/psychosocial history.

No addictions documented. 

CLINICAL FINDINGS

On examination: 

General Examination:

Pulse rate – 74/min.

Respiration rate – 16/min.

Blood Pressure – 130/90 mm of hg.

Height – 165 cm.

Weight – 70 kg.

BMI – 25.4 kg/m2 

Systemic Examination:

Urogenital system

Inspection:

Bipedal edema          –   Present.

Conjunctival pallor   –   Absent.

Sacral edema             –   Absent.

Urimic complexion   –   Absent.

Palpation:

Kidneys      -  Not ballotable.

Bladder       -  Not palpable.

No tenderness over renal angle and supra pubic region.

Percussion:

Renal bruits  –  Could not elicit.

Urine voiding symptoms

Frequency       –  Increased. 

Nocturia          –  Present.

Fatigue            –  Present.

Incontinence   –  Absent. 

Pain during micturition – Absent.

Cardiovascular and respiratory system –

No abnormality detected.

Locomotory system:

Ankle joint

Inspection:

Swelling– Present (B/L)

Palpation:

Pitting edema– Present (B/L)

ROM :

Flexion and Extension – Possible with pain (B/L)

TIMELINE

Image 1. Timeline of events added below

DIAGNOSTIC ASSESSMENT

Modern Diagnostic parameter; The biomedical diagnosis was confirmed by the Ayurvedic physician based on the clinical evaluation and lab investigations. 

Image 2. Baseline report dated 28.4.2019

Ayurvedic Assessment was done based on the presenting complaints and clinical evaluation. The treating physician confirmed the Ayurvedic diagnosis as Prameha janya abhyantara vidradhi pidaka. 

Ashtastana Pareeksha done: 

Nadi          – Drutham

Mootram   - Bahalam, Peetam, Phenilam, Visragandham.

Malam       - Baddham, Alpam.

Jihva          - Aliptham

Sabda        - Vyaktham

Sparsa       - Anushnaseetam

Drik           - No Pramehajanya timira, Eshata tamra. 

Akruti        - Sthoolam.

Differential Diagnosis- 

Organ-specific inflammatory conditions that have correlations with microalbuminuria are periodontitis, obstructive respiratory disease, hepatitis, bowel disease, pancreatitis, rheumatoid arthritis, and psoriasis. Based on the clinical evaluation and the lab investigations, the biomedical diagnosis was confirmed.

Prognosis: Microalbuminuria is an important clinical finding because it is not only associated with an increased risk of progression to overt proteinuria (macroalbuminuria) and renal failure, but also cardiovascular events. In patients with type 2 diabetes mellitus, hypertension, a decline in renal function may occur when albumin excretion is still in the normal range. In this case report, the patient is a known case of Type 2 Diabetes mellitus since 14 years and with hypertension. With one month of Ayurvedic treatment, the urinary albumin excretion level has reached within normal limit and the patient got relief from all the symptoms.

THERAPEUTIC INTERVENTION

Refer the tab ‘Treatment’ in the Portal. 

FOLLOW-UP AND OUTCOMES

The patient had 2 follow ups in total. The subjective and objective parameters were assessed. 

Clinician-based assessment; With 30 days of treatment, general debility of the patient reduced. Patient got complete relief from frothiness of urine and bilateral ankle swelling. 

Patient-assessed; Not relevant

Image 3. Lab reports taken at endpoint dated 10.6.2019

Table 1. The subjective and objective parameters tabulated before and after treatment.

OBSERVATIONS	BEFORE TREATMENT (29/4/2019)	AFTER TREATMENT (29/5/2019)
24 Hr. Urine Microalbumin level	100 mg/ day	30 mg/ day
Frothiness of urine	Present	Absent
General debility	Present	Reduced
Oedema of feet	Present	Absent

Intervention adherence and tolerability – The patient adhered to the prescribed treatments and tolerated the treatments well. 

Method of assessment- Lab investigations and symptoms were the primary assessment criteria. 

Adverse and unanticipated events; None reported

DISCUSSION: 

In Microalbuminuria, there are subtle changes in the renal microstructures and are reversible. The chikitsa adopted must be Apatharpana focusing on kleda medo shoshana and tridosha shamana.The ingredients of Njara Njavaladi Kashaya are having pramehahara, kaphamedohara, mutrala, vatanulomana, raktha pitta sodhana and rasayana properties. Most of the drugs have kashaya tikta rasa, laghu ruksha guna, and katu vipaka. The kashaya rasa and laghu ruksha guna helps in shoshana of kapha, kleda and medas which can reduce the arterial proliferation and nodular sclerosis. The tikta rasa and shita virya of the drugs helps in pitta rakta shamana which can act on the vascular endothelium and control the renal hypertension. The katu vipaka helps in reducing the kapha and medo dushti.

PATIENT’S PERSPECTIVE

Not available. 

LEARNING POINTS/TAKE HOME MESSAGES 

This case report highlights the clinical efficacy of ayurveda in treating microalbuminuria using a very simple formulation, and within a short span of time. 

INFORMED CONSENT

Written consent obtained from patient for publishing of the case report in the Portal 

ACKNOWLEDGEMENTS

None

CONFLICT OF INTEREST

None declared.

FUNDING

None

REFERENCE

    1.  https://www.verywellhealth.com/microalbuminuria-overview-4684503