Ayurvedic management for diabetic nephropathy:a case study

Rishu Sharma,Alok Km.Srivastava,Gyanendra D ShuklaDepartment of Panchkarma,Rishikul Campus,U.A.U,Haridwar;Department of Panchkarma,Main Campus,U.A.U,Haridwar;Department of Panchkarma,Gurukul Campus,U.A.U,Haridwar.

Keywords:Chronic renal failure,Diabetic nephropathy,Pedal edema,Prameha janya upadrava,Renal transplant

Background

It takes only a short span of time for diabetic kidney disease to become the leading cause of end stage renal disease (ESRD) [1,2].This microvascular complication develops in approximately 30% of patients with type 1 diabetes mellitus (DM) and approximately 40% of patients with type 2 DM [2,3].Diabetic nephropathy (DN) is the leading cause of ESRD worldwide,and it is estimated that 20% of type 2 diabetic patients reach ESRD during their lifetime[4].This is also a major cause of chronic renal failure as it accounts for 20–40% patients of chronic renal failure [5].Initially,it is manifested as a biochemical abnormality.Eventually,loss of excretory,metabolic and endocrine function of the kidney leads to the development of the clinical symptoms and signs of renal failure,which are referred to as uremia[6].

As per classical texts of ayurveda,UpadravasofPramehaareHrillas(nausea),Chhardi(vomiting),Shotha(edema),Avipaka(indigestion),Hikka(hiccups).These symptoms are seen as a result ofUpadravasdue toKaphaandPitta(two out of three basic humors of human body).Though complications ofPramehaare well written in all classical treatises yet there is no clear mention of pathology that can clarifyDosha-dushyasammurchchhana(pathophysiology) involved in the case.Also,clinical features ofVrikkarogamentioned in‘Bhaishajyaratnavali’matches very well with sign and symptoms of DN.Acharyas have advised in this condition to use combination of herbal medicines which have functions likeMutral(diuretics),Deepena(stimulant),Pachana(digestant),Raktaprasadak(blood purifiers),Virechaka(laxatives)and Rasayana(rejuvinators).

Why need of ayurveda in this disease?

The social and economic consequences of advanced stage of DN are considerable and the conventional approach of management includes dialysis and renal transplantation which is not affordable and acceptable by Indian population.Therefore,exploration of a safe and alternative therapy is highly needed,which proves to be helpful in reducing the requirement of dialysis or postponing the renal transplantation.

Case description

A male patient of 45 years presented in outpatient department of Panchkarma unit,Rishikul Ayurvedic College in September 2019 with Following complaints.Increased frequency of micturition from last 4 years;swelling in bilateral feet since last 3 years;reduced appetite &generalized weakness from past 1 year;severe nausea in the morning associated with headache from past 6 months,and presence of itching all over body from last 4 months.

Personal history Patient was not indulged in any form of substance use.

Treatment history

Patient was a known case of DM from past 4 years and was taking oral hypoglycemic drug (metformin 500 mg twice a day) for the same as prescribed by allopathic physician from past 4 years.

General examination

On general examination,patient’s nutrition was normal,pulse was 84/min,regular;blood pressure-120/80 mm of Hg,temperature-99.6 0F,respiratory rate-18/min.Other systemic examination was normal.Bilateral pedal edema(pitting type)was present.

TheSharirika prakritiof the patient wasKapha-vataja,hadMadhyama koshtha(normal bowel habits),Madhyama bala(optimum physical strength)withPravara satva(psychological strength).He hadAgnimandya(decreased digestion and appetite).

Investigations

Blood investigations revealed serum creatinine 6.95 milligram per deciliter (mg/dL),blood urea 99.0 mg/dL,blood sugar levels (fasting) was within normal limits,serum uric acid levels 7.6 mg/dL.Urine examination showed moderate protein (albumin +4)loss.Estimated glomerular filtration rate was 85.

Diagnosis

Ayurveda symptomatology ofPrameha upadravashowsChhardi(vomiting),Hrillas(vomiting),Daurbalya(weakness).As per Ayurvedic classics,theseUpadravaare due toKaphaandPitta.By clinical examinations and supported investigations,he was diagnosed as a case of DN,which was evidenced by ultrasonography of whole abdomen (including kidney and upper bladder).

Treatment plan

Patient received orally the following medication(Table 1).

Treatment outcome

After 10 days of treatment,bilateral pitting pedal edema,nausea and vomiting were reduced.After 30 days of treatment,there was marked reduction in serum creatinine levels (1.41 mg/dL) &serum uric acid levels (5.1 mg/dL) and significant changes in blood urea levels (43.40 mg/dL).Also,significant relief was seen inChhardi(vomiting),Hrillas(nausea),Daurbalya(general weakness).Patient was advised to continue the treatment for 1 month.Albumin level in urine was also reduced to (+2).The before and after treatment (after 1 month) parameters are shown as under in Table 2.

Table 1 Showing intervention details

Table 2 Showing before and after changes in investigations

Discussion

According to ayurveda,nephropathy is a disease ofMutravaha srotas.Though all the threeDoshasare involved in the disease,Kaphais responsible in blocking micro vessels and developing microangiopathy due to the fact that individuals withKapha prakritiare prone to obesity,diabetes and atherosclerosis.Damage in tissue can be repaired and prevented by the use ofRasayanaas they improve the nourishment,maintain the patency of theSrotasand improve the resistance of the tissues against any adversity.Any blockage can be removed by the preparations havingLekhana(scraping) effect on blocked micro vessels as well as macro vessels.The treatment plan was definite and all the medications were chosen due to their definite actions in this disease as:

Gokshuradi gugguluhavingGokshur,the main ingredient,is well known for itsRasayanaeffect,especially onMutravahasrotas.Guggulu(Commiphora mukul),another main ingredient,is aRasayan[7–9].and it hasLekhana(scraping) effect also.In addition,GugguluhasTridoshaharaproperty also,by which it pacifies all the threeDoshas.

Trinapanchmoolais combination ofKush(Desmostachya bipinnata),Kasha(Saccharums pontaneum),Shara(Saccharums munja),Ikshu(Sacharum officinorum),Kandeshu.The combination is well known for its effect on urinary system.It isTridoshghna,Mootraland works onVrikka roga[10].

Punarnava(Boerhavia diffusa) is an excellent medicine in this condition due to itsTridosha hara,Kapha-pitta shamak,Shotha-hara,Mutrajananproperties[11].

Hazrat yahood bhasma(silicate of lime) which isMootral,Pitta shamak,and reducesMutrakrichha[12].

Amalaki(Emblica officinalis) is well known for itsPramehaghna,RasayanandPittashamakeffect[13].

Shweta parpatihasMootralproperty so it washes out the impurities from blood through urination[14].

Yava ksharahasLekhanaproperty so it opens the channels ofMootra vahaandMedovaha strotas.Yava kshara is commonly used kshara formulation to treatShula(pain),Anaha(flatulence),Adhmana(abdominal bloating),Mutrakruccha(difficulty in micturition),Kanthavikara(diseases of throat) andAmlapita(acid-peptic disorder)[15].

Giloy satvais immune-modulator and has antioxidant property so it strengthens the body and protects from infection[16].

Conclusion

Thus,it can be concluded that ayurvedic approaches are helpful in managing complications like DN.This study emphasizes on the importance of integrated approach in healthcare.Considering such beneficial activities of ayurveda approaches;there is a need to undertake collaborative researches to generate evidences at larger scale in the management of DN.