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*Chronic debilitating illnesses (jeernajwara)
*Chronic debilitating illnesses (jeernajwara)
*Unknown causes (daiva)
*Unknown causes (daiva)
====[[Dosha]]- [[dhatu]] involvement in pathogenesis====
In this condition, there is involvement of all the three [[dosha]] with predominance of [[vata]] and [[kapha dosha]]. The bodily components that get vitiated in initial stage are urine (mutra), body fluids ([[rasa]], udaka, sweda, [[rakta]]) and blood vessels (sira). In later stages all the tissue components ([[dhatu]] and upadhatu) may get involved. Clinical conditions related to tendons (snayu), muscles tissue ([[mamsa]]), bones ([[asthi]]) and reproductive components ([[shukra]]) are often observed related to kidney diseases.
====[[Srotas]]====
In initial stage, channels([[srotas]]) like urinary (mutravaha), body water (udakavaha), sweat (swedavaha), body fluids (rasavaha) and blood (raktavahasrotas) are involved. But gradually it advances into a multi system disorder.
The pathological changes happening in the channels of urine(mutravahasrotas) in patients of chronic kidney diseases can be interpreted in terms of [[guna]] (inherent qualities). Excessive increase in characteristics like roughness (kharatwa), heaviness (gaurava), hardness (kathinya) and dryness (raukshya) leads to the structural damages in advanced stage.
The functions of [[agni]] are deteriorated at every level. Accumulation of intermediate products formed during digestion and metabolism ([[ama]]) is seen in every stage. The origin of all these pathological changes is colon (pakwashaya). The disease with initial involvement of middle pathway (madhyamarogamarga) progress to all the three disease pathways (rogamarga). This leads to poor prognosis.
===Principles of Management===
*First and most important step is avoiding causative factors (nidanaparivarjana) with treatment of underlying diseases.
*Repair of the damage at the site of origin for disease i.e., kidneys
*Establishing the normal state of channels of urine, body fluids and sweat by supporting the excretory functions and maintenance of fluid and electrolyte balance.
*Nourishment of the supportive tissues ([[dhatu]] poshana) especially [[rasa]], [[rakta]], [[mamsa]] and [[asthi dhatu]]. This includes correction of anaemia, myopathy, neuropathy, osteodystrophy etc.
*Management of associated problems such as cardiovascular disorders, hypertension etc.
*Psychotherapy (sattvavajayachikitsa) and spiritual therapy (daivavyapashrayachikitsa)
====I. Avoiding the cause (nidanaparivarjana)====
With the advice for avoiding the causative factors like dietary, life style modifications etc. the underlying disease conditions should be addressed first.
In cases of polycystic kidneys, manage the condition with suitable medicines like Kanchanaraguggulu, Varunadikwatha etc. For example, in case of hypertension, use of antihypertensive drugs to control blood pressure and overload on kidneys. In case of diabetic nephropathy, treatment for diabetes should be done first.
====II. Repairing the damage at kidneys (origin of disease)====
Herbs having [[rasayana]] (rejuvenating) activities on urinary system (mutravahasrotas) should be used. Crataeva religeosa (varuna), Boerrhavia diffusa (punarnava), Tribulus terrestris (gokshura), and Phyllanthus niruri (bhumyamalaki) show potent rejuvenating activities on urinary system. The compound preparation called “Chyavanaprasha”, other preparations like Jivitapradavati [Bheshaj Samhita] , shilajatwadivati etc. with [[rasayana]] drugs like black bitumen (shilajatu) and Commiphora wightii (guggulu) are found very effective for this purpose.
====III. Establishing the normal state of [[srotas]] (mutravaha, udakavaha and swedavaha)====
In order to support the excretory functions and maintenance of fluid and electrolyte balance, the therapeutic procedure called ‘[[basti]]’ is found highly effective. The decoction enema (niruha basti) with punarnavadi kwatha, and unctuous enema (anuvasana basti) with gokshuradi taila, the drug Boerrhavia diffusa (punarnava) in a palatable and convenient form 3-5 g twice a day is advisable.
Fluid intake should be regulated according to urine output. Excessive fluid intake is not advisable as it causes extra burden to the nephrons. However dehydration by restriction of fluids shall be prevented.
The status of important electrolytes like sodium and potassium should be considered. In cases of hypernatremia and associated cardiac failure, salt should be restricted. Rock salt (saindhava lavana) is advisable if needed. In cases of hyperkalaemia, intake of fruits and vegetables should be restricted. In case of hypokalaemia, intake of fruits and coconut water is useful.
====IV. Nourishment ofdhatu (body constituents)====
For correction of anaemia, Chyavanaprasha or any iron containing preparations are effective. Role of erythropoietin shall be considered here. If only the excretory function of kidney is impaired and endocrinal functions are proper, then erythropoietin supplementation is not needed. In case of deficiency of erythropoietin only, it should be supplemented. Fruits of prickly pear, beetroot are natural supplements having similar action to erythropoietin. These are used for promoting blood tissue ([[rakta dhatu]]).
For managing myopathy and neuropathy, a very effective therapeutic measure is massage (abhyanga) with medicated oils. This pacifies aggravated [[vata dosha]]. For osteodystrophy, Shankhabhasma, compounds of mukta (pearl) and pravala (coral) are used. They are good natural source of calcium and also help in managing hyperacidity. Mukta is an antidepressant too.
====V. Management of associated conditions====
In cases of hypertension, Triphala guggulu 1gm three times a day along with powder of Terminalia arjuna (3g) is effective. The powder of Rauwolfia serpentina (sarpagandha) 500mg-1gm can also be given to control hypertension. Symptomatic treatments are given in cases of nausea, vomiting, hiccup etc.
====VI. Psychotherapy====
Proper counselling of the patients, giving positive outlook and assurance comes under sattvavajaya chikitsa. This has a great role in such conditions.
===Treatment protocol===
====Purification therapies (shodhana chikitsa)====
In mild cases (creatinine <3mg%), mild therapeutic purgation ([[virechana]]) is advised after oleation ([[snehana]]) with gokshuradi ghrita. Then medicated enema ([[basti]]) with punarnavadi kwatha and gokshuradi taila is given.
If auto immune factors are involved, use of Piper longum (pippali) in the specific ascending and descending doses (vardhamana pippali) is recommended before [[virechana]] procedure.
====Pacification therapies (shamana chikitsa)====
Following medications are found effective in the management of kidney diseases.
*Gokshuradi guggulu-1g, three times a day, after food with warm water
*Varunadi kwatha - 40ml, two times a day
*Rasayana Churna [a combination of Tribulus terrestris (gokshura), Embilica officinalis (amalaka) and Tinospora cordifolia (guduchi)], 3g, three times a day with water
*Shvadamshtra Rasayana (powder of Tribulus terrestris (gokshura) triturated 7 times in the decoction of the same drug) 1g, three times a day
*Powder of Phyllanthus niruri (bhumyamalaki)– 3g, three times a day, after food, with water.
*Shilajatwadi vati-750mg, three times with water.
===Dietary protocol===
Breakfast: Chyavanaprashaavaleha 20g with 300ml boiled cow’s milk.
Lunch: Boiled green gram, green gram soup, boiled vegetables, rice. Fresh and mild spices are added.
Supper: Green gram soup, beans soup, rice, boiled vegetables with mild to moderate spices.
Others: Fruits (only papaya, grapes, sweet apple, figs and dates), pop rice.
An extra 100 ml of boiled milk (cow’s) is also advisable during day time, if the patient feels hungry.
Food items to be avoided:
*All other flour items like wheat, millet, corn etc.
*Bakery items, junk food, fermented items
*All oils except sesame oil
*Salts, sour substances
*Chilies, deep fried items
*Milk products except cow’s milk and ghee are to be avoided.
===Lifestyle factors===
Excessive physical and mental stress, day time sleep and night vigil are also restricted.