Case presentationDr. Amritha Edayilliam

Dept of PG studies in kayachikitsa

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Management of Chronic Kidney Disease with Rookshana involving Udwarthana and Triphaladi lekhana basthi- A case study

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VITAL DATA

• Name : Mrs. XYZ

• Age : 59 years

• Sex :Female

• Socio-Economic status : Rich

• Marital status :Married

• Education :Graduate

• Occupation : housewife

• Date of Admission

:20/05/2016

• Date of discharge: 4/6/2016

• Address : Hyderabad

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•Pain and burning

sensation while micturition

since 1 month.

•Fatigue since 4 years

aggravated since 1month.

•Puffiness of face on and off

since 4 years aggravated

since 1 month.

• Drowsiness

• Feeling breathlessness while

walking for short distance

since 4 years,

aggravated since 1 month.

• Giddiness while getting up from

bed, walking- since 10 years

aggravated since 1 month.

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CHIEF COMPLAINTS

ASSOCIATED COMPLAINTS

• Back pain

• Numbness over left lower limb on and off.

• Reduced appetite.

• Nausea on and off.

• Incomplete evacuation.

• Increased frequency of urine.

Since 4 years aggravated since 1month.

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• Patient is a k/c/o hypertension since 10 years and CKD since 4

years. All relevant blood examination done showed raised creatinine,

low GFR. For which medication was started. 1 month back suddenly

she developed fever with chills along with painful and burning

sensation while micturition. It was a squeezing type of pain which

develop prior, during and even after voiding the urine associated with

burning sensation. She developed puffiness of face (no periorbital

swelling)and swelling over bilateral feet persisting throughout the day

and lasting up to 3 days or more. For which they consulted their

physician and given symptomatic treatment. By which fever and

swelling over feet subsided. Puffiness of face, burning sensation and

painful micturition persisted. 6

HISTORY OF ILLNESS

• Simultaneously patient developed complaints of tiredness through

out the day, needs support to get up from bed, walking, climbing steps,

breathlessness while walking for short distances(from bed to till door)

, feeling sleepiness after taking a little quantity of food, no interest to

do any activities, reduced appetite and nausea. Pt also complaining of

backpain(lumbar region) non radiating which she feels like originating

from deep inside and numbness of left leg which will be during early

mornining, sitting for long hours.

• As she is undergoing regular checkup and taking treatment for CKD,

her consultant advised to start with dialysis as the kidney function tests

were much hampered. 7

• H/o haemorrhage in right eye

treatment for the same 6 year

back.

• H/o cataract in left eye 4 yr back

operated for the same.

• H/o Asthma in the year of 1987

subsided in same year.

• H/o headache for 20 yrs- used to

take painkillers.

• H/o Herpes 3 year back.

• H/o chicken pox age of 7.

• H/o UTI 1 year back

• Not a k/c/o DM, Hypothyroidism,

tuberculosis.

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PAST HISTORY

• Menarche at the age of 13.

• Menopause at the age of 45year (

2007).

• H/o severe menstrual bleeding,

for 6 years with dysmenorrhea.

For which she used to take

Meftalspas continuously for 15

days in the dose of 3 tab/day for 1

and ½ year along with brufen

occassionally(monthly thrice).

• P8 A6 L2 D0.

• All are induced abortions

• P2- Female age- 37 year

• P8- Female age-32 year.

• No h/o tubectomy done.

• H/o copper T contraception for 2

years.

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Menstrual history Obstetric history

• H/o 3 D&C in between 2002-

2007.

• On medication

• Tab Twincal BD

• Tab Prazopress XL 2.5mg OD

• Tab Dytor OD

• Tab Alpha ketoanalogue TID

• Tab PTH cinacalcet OD

• Tab Refil OD

• Cap. Oferol 0.25mg OD

• Epofit injection(weekly once)

• Cap. Rencap OD

• There was no family history

pertaining to the present illness.

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Treatment history Family history

• Diet - Mixed,

Nonveg – twice/week

• Appetite - reduced

• Sleep - disturbed

• Micturition – hourly once (10 times/day, 8 times/night),urgency +

• Bowels - once/day, hard stools (No clear evacuation)

• Habits-

• Sleeping after lunch >2 hours.

• Chilled softdrinks such Fanta, cococoala daily.11

Personal history

• Prakruti - Vata-Pitta

• Vikruti- Pravara

• Sara -Avara

• Samhanana -Avara

• Pramana -Madhyama

• Satmya - Vyamisra

• Satva - Avara

• Ahara sakthi- Avara

• Vyayama shakthi - Avara

• Vaya

Madhyama(parihani)

• Hetu - Shareerika- aharaja,

viharaja, abheshaja

Manasika nidanas

• Dosha -Tridosha prakopa

• Vata vikruti- Panchavata

• Kapha vikruti- Kledaka,

Avalambaka

• Pitha vikruti- Pachaka

• Desha - Jangala

• Kaala - Rithu-Sharath, Greeshma

• Bala -avara

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ROGI PAREEKSHA

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• A female patient obese built moderately nourished and afebrile, is

oriented to time place and in person

• P+ E0 N- transverse lines C0 Io L0

• Tongue - non coated

• Pulse - 75 BPM

• B.P - 150/100 mmHg

• Temp - 98.6° F

afebrile

• Respiratory rate - 18/min

• Height -150 cm

• Weight - 73kg

• BMI - 32.4

General examination

Per abdomen

Inspection

• Shape of abdomen- Distended

• Umbilicus- inverted , centrally

placed

• Palpation

• Soft.

• Tenderness – Epigastrium

left Hypogastrium

Umbilical

Left iliac.

• No rebound tenderness.

• No organomegaly

• Percussion and auscultation-NAD 14

Kidney &Urinary system

Costovertebral tenderness-+

Urgency-+

Frequency-++

Dysuria +

• RS-

• Bilateral NVBS heard,

• Crepitation heard over right and left lower zone.

• CVS-

• S1 & S2 heard, no added sounds

• MSK

Tenderness over L1,L2, L3.L4

SLR- -ve

ROM- possible

Systemic examination

NIDANA

• Aharaja-

• Pradushta ahara,teekshna ahara,

• Atilavana,atikshara,

• Ati amla,katukahara,

• Masha,moolaka,

• Jalaja anoopamamsasevana,

• Dadhi,sura,

• Virudhahara

• Ati Snigdaahara

• Guruahara

• Sheetahara

• Abhishyandi bhojana

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• Viharaja

• Divaswapna, avyayama

• Abheshaja

• Meftalspas 3 tab/day for 1 ½ year,

• Brufen (monthly thrice) for 25 years

• Painkillers for headache for 20 years

• Manasika

• Chintyanam cha atichinthanath

ROGA PAREEKSHA

Aharaja

Viharaja

tridoshaprakopa

Rasa

Shonitha

dushti

Shirasoruk,Bhrama

,Rakta pradara,

vaivarnya,

agnisaada,tandra

Manasika

AbheshajaMamsa

medo dushti

Mootra

dushti16

Sthoulya

Doshaja basthimarmaabhighatha

Further intake of nidana

Akshiraga,visarpaGurugaatrata

Atidourbalya,AruchiKlama

Nidraathiyoga

Mehana shoola

Basthishoola

Mootraudavarta

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Mootravaha

sroto dushti

Pandu

Mootrakruchra

• Dosha-

• Kapha Pitha pradhana tridosha

• Dushya -

• Rasa, rakta, mamsa, meda,

mootra

• Agni -Jataragni, dhatvagni

• Ama - Tadjanya

• Srothas

Rasavaha, Raktavaha,

Mamsavaha, Medovaha,

Mootravaha.

• Srotho dushti prakara – sanga

• Udbava sthana Amapakwashaya

• Vyaktha sthana-

Basthi, Mootravaha srothas.

• Adhishtana - Basthi.

• RogaMarga - Madhyama

• Sadhyasadhyatha - Yapya

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Samprapthi ghataka

• Previous investigation reports on 14/5/16

• Serum creatinine- 7.70 mg/dl

• Blood urea- 106.3 mg/dl

• GFR- 10

• Peripheral smear test-Normocytic hypochromic

• Parathyroid hormone-479pg/ml (raised)

• Urine analysis

• Appearance- clear,

• Sp. Gravity- 1.005

• Protein- present, Sugar- present, pus cells- 15- 20 hpf

• Epithelial cells- 6- 8

• RBC- nil, Cast- nil

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INVESTIGATIONS

• Ayurveda

• Kaphaja shotha

• Basthi marmaabhighatha

• Mootrakruchra

• Kaphaja prameha

• Modern science

• Chronic kidney disease

• Nephrotic syndrome

• Pylonephritis

• Cystitis

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Vyavachedaka nidana

• Doshaja basthi

marmabhighata

• Vangshna shoola

• Mehana shoola

• Basthishoola

• Udavartha

• Jwara

• Mootrakruchra

• Mootrakruchra

• Teevrarthi ruk vangshna, basthi

• Swalpam muhu mootrayateeha

• Sarujam, sadaaham,kruchram

muhurmootrata.

• CKD

• Presence of markers of kidney

damage> 3 months,

• Functional abnormality of kidney

with decreased GFR, anaemia,

hypertension, raised PTH,

nausea,reduced appetite, H/O

peripheral oedema

• Cystitis

• Frequency,

• Urgency,

• Dysuria,

• Burning micturition, pyuria,

• Hypogastric discomfort.21

• Sarvanga udwarthana with triphala churna + manjishtachurna + kolakulathadi churnafollowed by nadi sweda-(14 days)

• Sarvanga takradhara with musta,amlaki(5 days)

• Triphala niruha (yogabasthi)

• Anuvasana- triphalathaila(100ml)

• Niruha - triphala kwatha

• Honey-30ml

• Saindhava- 5 gm

• Triphala thaila-100ml

• Katuki churna- 20gm

• Triphala kwatha- 400ml

• Internal medication

• Pippalyasava+

Bringarajasava+Veeratharvadi

kashayam+Varanaadi kashayam-

8tsp tid

• Tab Chandraprabha vati 2-2-2.

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TREATMENT ADOPTED

•Tiredness

•Breathlessness

•Anorexia

•Nausea

•S. creatinine

•Blood urea

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Assessment criteria

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Tiredness Breathlessness Anorexia Nausea

0. no tiredness 0. No

breathlessness

0. Takes full diet and also

presence of proper appetite at

the next meal hour.

0. no nausea

1. occasional

feeling of

tiredness on

activity

1. breathlessness

on quick

moving/upstairs

1. Presence of moderate

apetite and proper appearance

of appetite in next meal hour

1. less than 2

times

2. Constant

feeling of

tiredness on

activity

2. breathlessness

on light physical

activity.

2. Presence of moderate

apetite but delayed appearance

of appetite in next meal hour

2. 2-5 times

3. Feeling

tiredness all the

time

3. breathlessness

on bed

3. presence of low appetite

and delayed appearance of

appetite in next meal hour

3. >5 times

• OBSERVATION

• On 31/5/16

• S.creatine-7.6

• Blood urea- 87.6

• Puffiness of face reduced 50%,

• Tiredness reduced 40%,

• No pain and burning sensation while micturition

• Back pain reduced 95%.

• Bowel- complete evacuation

• Bladder- 6 times/day, 4 times at night.(complete evacuation) no urgency.

• On 4/7/16

• Blood urea- 75.6mg/dl

• S .creatinine – 7.4 mg/dl

BT AT

Tiredness 3 2

Breathlessn

ess

2 1

Anorexia 3 1

Nausea 3 1

S.creatinin

e

7.70mg/dl 7.4mg/dl

Blood urea 106.3mg/dl 75.6mg/dl

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• Chronic kidney disease is progressive loss in renal function over a

period of months or years and is caused by any condition which

destroys the normal structural properties possibly help to transport the

drug molecules in the systemic circulation through mucosa.

• The treatment modality adopted here based on the dosha dushya

involvement.

• Since the patient was mamsala medura and dosha involved was kapha

pitha, rookshana was done in the fom of udwarthana , takradhara and

lekhana basti was selected.

• The drugs selected for lekhana basthi are capable of liquefying viscid

matter and breaking into minuteminute particles ang helping in

doshavilayana. Along with that Saindhava lavana helps in removal of

doshas by its lekhana property.

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Discusssion

• Triphala is rich source of galic acid, tannins exhibits anti oxidant anti inflammatoryand detoxification activities. It is rasayana, tridoshahara, amapachaka action which helps in rejuvenating damaged capillaries apart from improving blood circulation and GFR.

• Katuki help to bring collective benefits for its pitha rechaka and kaphahara action. Varunadi Kashaya which mentioned as varunaadigana which possess the quality of kapha medo hara and agnipradeepana, the contents of veeratharvadi Kashaya which mentioned as veeratharvadi gana possesses quality like mootrala and acts on mootrakruchra mootraghata rujahara.

• Presence of pippali in pippalyasava enhances the bio availabilioty and thus allowing the faster penetration of phytomolecules. Bhringaraja in bringarajasava act as anti inflammatory antimicrobial activity thus pacifies chronic, non specific UTI with CKD

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Conclusion

• In this case Basthi is very much effective in improving the kidney

functions and basthi dravyas and shamanaoushadis used in this case

having srothovishodhana property.

• This treatment approach is safe and effective in cases of CKD, Further

studies to be conducted to establish the facts with more statistical and

scientific strength.

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Thank you29