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TITLE OF CASE

Integrative management of chronic renal failure - A case report

Dr Pankaj Chayyani

ABSTRACT

A 38-year-old male patient complained of bilateral pedal oedema, moderate breathlessness, and blurred vision along with severe generalized weakness and wet cough. The Biomedical diagnosis was made based on the USG as bilateral medical-renal disease[1] along with bilateral moderate to gross pleural effusion. His serum creatinine level was recorded as 21.5mg/dl. Patient was then referred to higher centre for haemodialysis by the Nephrologist The patient underwent haemodialysis on daily basis from 26th March 2021 to 1st April 2021 supported with medications for symptomatic management. The haemodialysis schedule was changed to thrice a week for one month. Further he was suggested for renal transplant. The patient now consulted Dr Pankaj Chayyani and the Ayurvedic diagnosis made was Vrikka dosa [2]. As the tridosa are involved in the pathogenesis, the treatment was planned to address this along with Rasayana cikitsa, and Vasti karma. Specific allopathic medications were continued during Ayurvedic treatment. Haemodialysis was done when the clinical features of uraemia appeared, or the serum creatinine level was greater than 12. With Ayurvedic treatments, haemodialysis could be stopped completely, and serum creatinine was normal and stable. His symptoms of bilateral pedal oedema, breathlessness, blurred vision, generalised weakness, and wet cough were completely relieved.

KEYWORDS

Renal, kidney, renal failure, case report, integrative, vrikka dosa

INTRODUCTION

Chronic kidney disease (CKD) arises from many heterogeneous disease pathways that alter the function and structure of the kidney irreversibly, over months or years. Diabetes and hypertension are the main causes of CKD. Many people are asymptomatic, and present after chance findings from screening tests—for example, through a routine medical examination or check-up—or not until they become unwell with advanced CKD. However, depending on the cause of CKD, the symptoms may present directly because of impaired kidney function.

Diagnostic Criteria- Renal ultrasound is generally considered the preferred first-line imaging technique for the assessment of people with previously undiagnosed kidney dysfunction. Diagnostic criteria include 1 or more of the following: (1) GFR less than 60 mL/min/1.73 m2; (2) albuminuria (ie, urine albumin ≥30 mg per 24 hours or urine albumin-to-creatinine ratio [ACR] ≥30 mg/g); (3) abnormalities in urine sediment, histology, or imaging suggestive of kidney damage; (4) renal tubular disorders; or (5) history of kidney transplantation. Based on previous treatment records and the clinical examination, the clinician diagnosed this patient as Chronic Renal Failure.

PATIENT INFORMATION

A 38-year-old male patient complained of bilateral pedal oedema, moderate breathlessness, blurred vision, severe generalized weakness, and wet cough for 2 months.

Medical History: The patient was healthy until 26th March 2021. Two days before, he complained of bilateral pedal oedema, moderate breathlessness, blurred vision, and severe generalized weakness and wet cough. The patient was diagnosed with bilateral medical-renal disease along with bilateral moderate to gross pleural effusion. Serum creatinine level 21.5mg/dl. Patient was then referred to a higher centre for haemodialysis by the nephrologist The patient was treated with hemodialysis on daily basis from 26th March 2021 to 1st April 2021 along with other symptomatic allopathic treatment. After 1st April, the haemodialysis was done thrice a week for one month. The symptoms persisted in spite of treatments. Hence he was suggested renal transplant.

CLINICAL FINDINGS

Pedal edema+, pallor of tongue and sclera

TIMELINE

Image 1. Timeline of events added

DIAGNOSTIC ASSESSMENT

Modern Diagnostic parameter: USG abdomen confirmed the diagnosis as medical renal disease.

Image 2. USG abdomen is attached below

Image 3. Creatinine and CRP values recorded at baseline added below

Ayurvedic Assessment was done based on the clinical evaluation by the ayurvedic physician. The biomedical diagnosis was Chronic renal failure.

Differential Diagnosis- This does not apply as the patient came in with a definite diagnosis.

Prognosis- Chronic renal failure or ESRD (End stage renal disease) is a progressive, irreversible deterioration in renal function in which the body’s ability to maintain metabolic and fluid and electrolyte balance fails resulting in uremia or azotemia. With Ayurvedic treatment, hemodialysis could be stopped with a marked reduction in biochemical parameters.

THERAPEUTIC INTERVENTION

See the tab ‘Treatment details’

FOLLOW-UP AND OUTCOMES

Clinician-based assessment; The frequency of haemodialysis was reduced. For 7 months, the patient did not undergo haemodialysis. The serum creatinine level became normal and stable. The other parameters like Hb, urea, potassium, sodium, and phosphate also reduced significantly. The patient also got significant relief in clinical features like blurred vision, pedal oedema, breathlessness, generalised weakness, anorexia and cough

Patient assessed: Not relevant.

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

Method of assessment- By monitoring the patient.

Adverse and unanticipated events; None reported.

DISCUSSION ;

All three doṣas are involved in patients of chronic renal failure. Treatment is to be planned according to involved doṣas, rasayana cikitsa along with pancakarma mainly basti karma. Varunadi kvatha is helpful in kidney problems and it alleviates kapha and medas. Goksura is also effective and an established herb to manage kidney problems. Goksura is also balya aushadhi. Svadamstra rasayana is goksura bhavita goksura.Goksuradi gugglu is indicated in the treatment of mutraghata, mutrakricchra, prameha and disorders of vata. (Sharngadhara madhyama khanda adhyaya-7) Punarnva and iksumula have mutrala (diauresis) action and it is always beneficial to use herbs instead of modern loop diuretics as they can cause nephrotoxicity. Yavaksara also has mutrala effect and also helpful in gastric problems. Nagarjunabhra rasa and Javaharamohararasa are good for heart so both are given to improve cardiac function. The excretion of mutra and purisa is one function of apana. Both basti and nadi svedan improve apana function. Sharapunkha and bhumyamalaki have role in rakta dhatu formation by acting on liver. Basti through their effect on the seat of vata promote excretory function.  Integrated effects of all therapies, medicaments, and wholesome food and behaviour may counteract the disease process and, to some extent, can also revert the process.

PATIENT’S PERSPECTIVE

Not available.

LEARNING POINTS/TAKE-HOME MESSAGES

The patient was suggested renal transplant owing to the non-satisfactory response to conventional medications. With ayurvedic treatment, the patient did not require haemodialysis for seven months. There was a marked reduction in his biochemical parameters. This case report demonstrated the successful integrative management of chronic renal failure. .

INFORMED CONSENT

Written consent obtained from patient’s parents.

CONFLICT OF INTEREST

None declared.

FUNDING

None

REFERENCE

1. Osborne CA, Low DG, Johnson KH. Renal disease. Vet Clin North Am. 1971 May;1(2):323-53.

2. Dr. Sharda Tak and Prof. Mahesh Chandra Sharma. Clinical study of “gokshuradi yoga” for the management of chronic renal failure. WJPR. Vol 6, Issue 16, 2017.

Image 1. Timeline

Image 2. USG abdomen dated 26.03.2021 

Image 3. Creatinine and CRP values recorded at baseline