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==([[Nidana Sthana]] Chapter 4, Chapter on Chronic Urinary Disorders, or ''Prameha'')==

==([[Nidana Sthana]] Chapter 4, Prameha Nidana (Chapter on Diagnosis of Obstinate Urinary Disorders)==

=== Abstract ===

=== Abstract ===

===== ''Sahaja prameha''/ ''jatah pramehi'' (hereditary) =====

===== ''Sahaja prameha''/ ''jatah pramehi'' (hereditary) =====

In [https://en.wikipedia.org/wiki/Ayurveda Ayurveda], the words ''sahaja'' and ''jatah'' indicate genetic predisposition to the disease.  

In Ayurveda, the words ''sahaja'' and ''jatah'' indicate genetic predisposition to the disease.  

Broadly, in hereditary diseases there may be two contributing factors:

Broadly, in hereditary diseases there may be two contributing factors:

===== Classification by ''Dosha''/Stage of Progression =====

===== Classification by ''Dosha''/Stage of Progression =====

As for all other disease systems described in Ayurvedic texts, ''prameha'' has been classified according to the predominant ''dosha'' in the disease process. [https://en.wikipedia.org/wiki/Ayurveda Ayurveda] describes three distinct categories of ''prameha'' by ''dosha'', i.e., ''kaphaja, pittaja,'' and ''vataja prameha''<ref> Shastri KN, Chaturvedi GN. Agnivesha, Charaka Samhita, Vidyotini Commentary. Varanasi, India : Chaukhamba Bharti Academy, 2004. </ref> <ref> Shukla VD, Tripathi RD. Agnivesha, Charaka Samhita, Vaidyamanorama Hindi Commentary. Delhi, India; Chaukhamba Sanskrit Pratisthana, 2002. </ref>. However, it is important to note here that the dominance of a ''dosha'' varies as the disease progresses. In the initial stage, ''kapha'' is in excess, which vitiates ''meda'' and ''kleda'' causing ''kaphaja prameha''.  

As for all other disease systems described in Ayurvedic texts, ''prameha'' has been classified according to the predominant ''dosha'' in the disease process. Ayurveda describes three distinct categories of ''prameha'' by ''dosha'', i.e., ''kaphaja, pittaja,'' and ''vataja prameha''<ref> Shastri KN, Chaturvedi GN. Agnivesha, Charaka Samhita, Vidyotini Commentary. Varanasi, India : Chaukhamba Bharti Academy, 2004. </ref> <ref> Shukla VD, Tripathi RD. Agnivesha, Charaka Samhita, Vaidyamanorama Hindi Commentary. Delhi, India; Chaukhamba Sanskrit Pratisthana, 2002. </ref>. However, it is important to note here that the dominance of a ''dosha'' varies as the disease progresses. In the initial stage, ''kapha'' is in excess, which vitiates ''meda'' and ''kleda'' causing ''kaphaja prameha''.  

Further progression results in the loss (or ''kshaya'') of ''kapha''. ''Pitta'' then predominates, which vitiates the blood (''rakta''), precipitating ''pittaja prameha''. Further progression results in loss of ''pitta''. This leads to vitiation of ''vata'', which weans the body of vital substances/vital essence through urine, precipitating ''vataja prameha''<ref> Chandola HM, Bhatia S. Concept of Diabetes mellitus in Ayurveda and its treatment with certain indigenous drugs. AYU Int 2001;1:84-87. </ref>. Charaka says that any of these three types of ''prameha'' can be precipitated directly, depending upon genetic predisposition and improper diet and lifestyle.  

Further progression results in the loss (or ''kshaya'') of ''kapha''. ''Pitta'' then predominates, which vitiates the blood (''rakta''), precipitating ''pittaja prameha''. Further progression results in loss of ''pitta''. This leads to vitiation of ''vata'', which weans the body of vital substances/vital essence through urine, precipitating ''vataja prameha''<ref> Chandola HM, Bhatia S. Concept of Diabetes mellitus in Ayurveda and its treatment with certain indigenous drugs. AYU Int 2001;1:84-87. </ref>. Charaka says that any of these three types of ''prameha'' can be precipitated directly, depending upon genetic predisposition and improper diet and lifestyle.  

Modern scientific research also correlates insulin resistance with obesity, where insulin resistance increases with weight gain and reduces with weight loss. Hormones such as resistin (derived from adipose tissues) provide for a direct link between obesity and diabetes, as they cause insulin resistance.<ref> Kumar Manish, Kivadassanavar MB et al. Screening of Serum Insulin in Obese Individual WSR to Sthaulya: An Observational Study. 2016. European Journal of Pharmaceutical and Medical Research, 2016,3(9),638-640 </ref>  

Modern scientific research also correlates insulin resistance with obesity, where insulin resistance increases with weight gain and reduces with weight loss. Hormones such as resistin (derived from adipose tissues) provide for a direct link between obesity and diabetes, as they cause insulin resistance.<ref> Kumar Manish, Kivadassanavar MB et al. Screening of Serum Insulin in Obese Individual WSR to Sthaulya: An Observational Study. 2016. European Journal of Pharmaceutical and Medical Research, 2016,3(9),638-640 </ref>  

In [https://en.wikipedia.org/wiki/Ayurveda Ayurveda], much emphasis has been given to the role of ''meda'' in the pathogenesis of ''prameha''. However, its role is not only as a ''dushya'' (disturbed functioning of the ''dhatus''), but something more than that. ''Bahudrava shleshma'' (''kapha'' that contains too much liquid) joins and affects ''meda'', causing it to become ''abadha'' (unobstructed or fluid) in nature. This form of ''meda'' has been described to have an effect on ''mamsa'' (muscle tissue), thereby increasing the volume of body fluid. This has been described as ''sharira- kleda'' (body fluid). This route of pathogenesis for ''prameha'' is closely related to obesity.

In Ayurveda, much emphasis has been given to the role of ''meda'' in the pathogenesis of ''prameha''. However, its role is not only as a ''dushya'' (disturbed functioning of the ''dhatus''), but something more than that. ''Bahudrava shleshma'' (''kapha'' that contains too much liquid) joins and affects ''meda'', causing it to become ''abadha'' (unobstructed or fluid) in nature. This form of ''meda'' has been described to have an effect on ''mamsa'' (muscle tissue), thereby increasing the volume of body fluid. This has been described as ''sharira- kleda'' (body fluid). This route of pathogenesis for ''prameha'' is closely related to obesity.

==== ''Samprapti'' (pathogenesis) of ''prameha'' ====

==== ''Samprapti'' (pathogenesis) of ''prameha'' ====

The pathogenesis of ''vataja prameha'' is similar to that of type-1 diabetes mellitus. ''Vata'' is agitated due to various precipitating causes acts on the body in such a way that there is passage of ''vasa'' (fat), ''majja'' (bone marrow), ''lasika'' (lymph), and ''ojas'' (essence of the body /immune substances / vitality) through the urine. This condition indicates impaired renal function as a result of diabetes, leading to a dire prognosis. Due to ''dhatukshaya'' (loss of body tissues) the patient become very weak and emaciated.

The pathogenesis of ''vataja prameha'' is similar to that of type-1 diabetes mellitus. ''Vata'' is agitated due to various precipitating causes acts on the body in such a way that there is passage of ''vasa'' (fat), ''majja'' (bone marrow), ''lasika'' (lymph), and ''ojas'' (essence of the body /immune substances / vitality) through the urine. This condition indicates impaired renal function as a result of diabetes, leading to a dire prognosis. Due to ''dhatukshaya'' (loss of body tissues) the patient become very weak and emaciated.

[[Charaka Samhita]] deals with very specific pathogenesis for ''madhumeha'', which is a subtype of ''vataja prameha''. When an individual excessively consumes the foods that cause ''prameha, kapha'' and ''pitta'' become vitiated, then adipose tissues and muscle tissuses become disturbed and causes impaired functioning of ''vata''. Subsequently ''vata'' gets vitiated and extends to urinary bladder along with ''ojas'', resulting in ''ojas'' being expelled in the urine. In [https://en.wikipedia.org/wiki/Ayurveda Ayurveda], ''ojas'' is considered vital to the maintanence of health; its loss in ''prameha'' leads to many complications, including ''prameha pidika'' (boils and carbuncles). This advanced condition is comparable to non-insulin –dependent type -2 diabetes progressing into insulin dependent diabetes. It is the stage of diabetes in which there are complications, including nephropathy, which result in vital substances of the body being excreted through urine.

[[Charaka Samhita]] deals with very specific pathogenesis for ''madhumeha'', which is a subtype of ''vataja prameha''. When an individual excessively consumes the foods that cause ''prameha, kapha'' and ''pitta'' become vitiated, then adipose tissues and muscle tissuses become disturbed and causes impaired functioning of ''vata''. Subsequently ''vata'' gets vitiated and extends to urinary bladder along with ''ojas'', resulting in ''ojas'' being expelled in the urine. In Ayurveda, ''ojas'' is considered vital to the maintanence of health; its loss in ''prameha'' leads to many complications, including ''prameha pidika'' (boils and carbuncles). This advanced condition is comparable to non-insulin –dependent type -2 diabetes progressing into insulin dependent diabetes. It is the stage of diabetes in which there are complications, including nephropathy, which result in vital substances of the body being excreted through urine.

Among patients with significant proteinuria, the degeneration of cells within epithelial casts may result in a characteristic "Maltese Cross" appearance and a fatty cast. These droplets are composed of cholesterol esters and cholesterol, which may also be observed free in the urine. This may be correlated with ''vasameha'' (lipiduria). ''Majjameha'' can be correlated with appearance of waxy casts in urine in advanced renal failure. Waxy cast are thought to be the last stage of the degeneration of a granular cast. Since this degenerative process is probably slow, it is most likely observed in nephrons with much diminished flow. Waxy casts are therefore most consistent with the presence of advanced renal failure.<ref> https://www.slideshare.net/sprince33/glomerulonephritis accessed on 12 June 2017 </ref>   

Among patients with significant proteinuria, the degeneration of cells within epithelial casts may result in a characteristic "Maltese Cross" appearance and a fatty cast. These droplets are composed of cholesterol esters and cholesterol, which may also be observed free in the urine. This may be correlated with ''vasameha'' (lipiduria). ''Majjameha'' can be correlated with appearance of waxy casts in urine in advanced renal failure. Waxy cast are thought to be the last stage of the degeneration of a granular cast. Since this degenerative process is probably slow, it is most likely observed in nephrons with much diminished flow. Waxy casts are therefore most consistent with the presence of advanced renal failure.<ref> https://www.slideshare.net/sprince33/glomerulonephritis accessed on 12 June 2017 </ref>   

A burning sensation in the hands and feet is an important feature of neuropathy that results from diabetes mellitus. Excessive sweat as a consequence of obesity may result in bacterial growth that leads to body odor. Excessive thirst may be directly related to disturbed glucose metabolism. Thus, the symptoms described in the ''poorvarupa'' of ''prameha'' include prediabetic symptoms and the early manifestation (vascular changes, obesity, etc.) of diabetes or subclinical diabetes.

A burning sensation in the hands and feet is an important feature of neuropathy that results from diabetes mellitus. Excessive sweat as a consequence of obesity may result in bacterial growth that leads to body odor. Excessive thirst may be directly related to disturbed glucose metabolism. Thus, the symptoms described in the ''poorvarupa'' of ''prameha'' include prediabetic symptoms and the early manifestation (vascular changes, obesity, etc.) of diabetes or subclinical diabetes.

The role of ''meda'' (fat/adipose tissues) is of great importance in the pathogenesis of ''prameha''. Its role is not as ''dushya'' (disturbed functioning of the ''dhatus''), but something more than that. According to [[Charaka Samhita]], ''bahudrava shleshma'' (kapha that contains too much liquid) joins and affects ''meda'', causing it to become ''abaddha'' (unobstructed or fluid) in [https://en.wikipedia.org/wiki/Ayurveda Ayurveda]. This has been described as ''sharira-kleda'' (body of fluid) in [https://en.wikipedia.org/wiki/Ayurveda Ayurveda]. Thus, excess water in the blood causes increased diuresis. It is very important to elaborate the term ''bahudrava shlesma''. ''Shleshma/ kapha'' is one among the three basic humors regulating all physiological and psychological process in the living organism. At its normal state, it causes binding of body tissues i.e. maintain the tissues integrity, represent the normal cell mediated immunity etc. ''Bahudrava'' means that ''kapha'' loses its natural properties and get vitiated, it is important to mention here that this derangement may be acquired or congenital, Whatever may be the cause this vitiated ''kapha'', it is unable to perform its normal functions. Describing the physical properties of ''kapha'' it is mentioned that it is unctuous in touch and looks like ''ghrita'' (ghee). Thus, it can be said that ''kapha'' in body represents lipid components of the body and vitiated ''kapha'' can be correlated with dyslipidemia. Role of dyslipidemia and metabolic abnormalities in the pathogenesis of diabetes is very obvious and well elaborated in modern medicine. Among the metabolic abnormalities that commonly accompany diabetes are disturbances in the production and clearance of plasma lipoproteins. Moreover, development of dyslipidemia may be a harbinger of future diabetes. A characteristic pattern, termed diabetic dyslipidemia, consists of low high density lipoprotein (HDL), increased triglycerides, and postprandial lipemia. This pattern is most frequently seen in type 2 diabetes and may be a treatable risk factor for subsequent cardiovascular disease.<ref> http://press.endocrine.org/doi/10.1210/jcem.86.3.7304 accessed on 12 June 2017 </ref>

The role of ''meda'' (fat/adipose tissues) is of great importance in the pathogenesis of ''prameha''. Its role is not as ''dushya'' (disturbed functioning of the ''dhatus''), but something more than that. According to [[Charaka Samhita]], ''bahudrava shleshma'' (kapha that contains too much liquid) joins and affects ''meda'', causing it to become ''abaddha'' (unobstructed or fluid) in Ayurveda. This has been described as ''sharira-kleda'' (body of fluid) in Ayurveda. Thus, excess water in the blood causes increased diuresis. It is very important to elaborate the term ''bahudrava shlesma''. ''Shleshma/ kapha'' is one among the three basic humors regulating all physiological and psychological process in the living organism. At its normal state, it causes binding of body tissues i.e. maintain the tissues integrity, represent the normal cell mediated immunity etc. ''Bahudrava'' means that ''kapha'' loses its natural properties and get vitiated, it is important to mention here that this derangement may be acquired or congenital, Whatever may be the cause this vitiated ''kapha'', it is unable to perform its normal functions. Describing the physical properties of ''kapha'' it is mentioned that it is unctuous in touch and looks like ''ghrita'' (ghee). Thus, it can be said that ''kapha'' in body represents lipid components of the body and vitiated ''kapha'' can be correlated with dyslipidemia. Role of dyslipidemia and metabolic abnormalities in the pathogenesis of diabetes is very obvious and well elaborated in modern medicine. Among the metabolic abnormalities that commonly accompany diabetes are disturbances in the production and clearance of plasma lipoproteins. Moreover, development of dyslipidemia may be a harbinger of future diabetes. A characteristic pattern, termed diabetic dyslipidemia, consists of low high density lipoprotein (HDL), increased triglycerides, and postprandial lipemia. This pattern is most frequently seen in type 2 diabetes and may be a treatable risk factor for subsequent cardiovascular disease.<ref> http://press.endocrine.org/doi/10.1210/jcem.86.3.7304 accessed on 12 June 2017 </ref>

==== Causes of lipoprotein abnormalities in diabetes <ref> Goldberg J.Ira . Diabetic Dyslipidemia: Causes and Consequences .The Journal of Clinical Endocrinology & Metabolism. 2001.  86 (3): 965-971. </ref>====  

==== Causes of lipoprotein abnormalities in diabetes <ref> Goldberg J.Ira . Diabetic Dyslipidemia: Causes and Consequences .The Journal of Clinical Endocrinology & Metabolism. 2001.  86 (3): 965-971. </ref>====