Abstract

End Stage Renal Disease (ESRD) is becoming the most common disease and a major cause of death in India. In the modern science, there is no treatment except dialysis and then renal transplant. Both these treatments are not always successful. The patient, even after transplant has to take medicines and remain careful throughout his life. In a fair majority of cases, the body may not accept the other man’s kidney and the patient, even after spending a good amount of money dies. Moreover, both these treatments are beyond the reach of common person. The third disastrous scandal is that the doctor becomes dishonest for few chips of money. Hence it is the duty of an Ayurvedic physician to understand the disease according to modern science and Ayurveda both and then treat accordingly.
 
Introduction:

Ayurvedic vaidyas believe that there is no description of this disease in Ayurvedic texts, which is not correct. The description of Mootra-vaha strotas, its pathological changes, signs and symptoms and the disease of these strotas have been elaborately described. Functions of formation of urine takes place through Mootra-vaha strotas. Thus, one has to understand the physiology and pathology of these strotas, if he wants to find out the diagnosis and treatment of renal failure according to Ayurveda. Mootra-vaha strotas are those channels through which Mutra (urine) is being separated from blood.

Formation of Urine according to Ayurveda:

Vrikka or Kidneys, according to Ayurveda are (Moolas) of Medo-vaha strotas and not with formation of urine. It has some connection with meda dhatu (adipose tissues) and fat metabolism. Present knowledge is not able to clarify and explain this fact, but in future, it may be proved; the formation of urine takes place in ‘Pakwashaya’. Pakwashaya should not be understood as large intestine only. While describing koshta-angas (organs in the trunk). Charaka has mentioned (1) Amashaya, (2) Pakwashaya, (3) Sthoola antra and (4) Sukshma antra (5) Uttarguda and (6)A dhoguda separately. Thus Pakwashaya and Antra are two different organs.

In the same way, while describing diseases in ‘Rogaanika Vimaan’(Ch.Vi.7) Charaka has described two types of diseases – (1) Amashaya Samuttha (originating from amashaya), and (2) Pakwashaya Samuttha (originating from pakwashaya).

Thus, Pakwashaya is separate term used for physiological and pathological terms.

According to our interpretation (1) Amashaya means that organ where the nutrient material has to undergo changes i.e. digestion and metabolism and (2) Pakwashaya means the organ where the material that has undergone physiological change and end product has formed. Thus, for urinary apparatus Pakwashaya are nephrons and tubules of kidney i.e. mutravaha strotas. So urine formation according to Sushruta takes place in the following ways. The mutra-vaha nadies (urinary tubules) situated in Pakwashaya, dribble urine constantly like rivers to the Sea. These tubules are so tiny (sukshma) that their mouths (mukha-funnel) cannot be seen by open eyes. They are million in numbers. The urine brought from Amashaya is poured and is collected in Basti (urinary bladder) by the process of ‘Nishyanda’ (dribbling, cozing etc) day and night, whether awake or slept.  When the bladder is full, urinary sensation takes place and new urine is formed. From this, it is cleared that nephrons and tubules are the organs for formation of urine. Thus Pakwashaya does not mean only large intestine but those organs where end product of digestion & metabolism are formed, and collected and exerted out.

There are 3 types of waste matter: (1) Solid or (2) Semisolid and (3) Liquid and gaseous. The liquid waste matter is excreted through urine and perspiration. Non-excretion of waste matter and sanchaya (accumulation of waste matter in the body especially Rasa (Plasma) is called Ama-mal). Blood urea and creatinine accumulation are possibly called Ama. Thus, End Stage Renal Disease is a disease due to Amadosha.

Function of Urine:

Vikledacrit: This word means to excrete out the liquid waste and to make the body free from waste matter i.e. Purification of body. Some translate ‘vikleda’ as specific mala. Thus, stool, urine, perspiration are useful for purification of body. If any one of this is not properly excreted, they accumulate in the body and there is likelihood of disease.

Charaka says there are two types of body dhatus (tissues) – (1) Prasad bhoota (useful for the body) and (2) Mala bhoota (waste matter). Mala bhoota dhatus are vitiating the body. They are Bahirmukha (ready for excretion). The metabolic substances like urine or creatinine etc. are useful for maintaining the health, if they are normal. However, any increase of these substances and retention in the body are harmful.

Types of Vitiation of Srotas:

In general all types of srotas undergo four types of vikriti i.e. pathological changes viz. Atipravitti (excessive flow), Sanga (obstruction in the flow), Sira granthi (growth benign or malignant, cystic or hard), Vimarga gaman (flow of other direction then useful) i.e. extravasations.  Kidney disorders also undergoes any of the above changes. There may be one type of Vikriti or may be more than one type. In the disease of mutra-vaha srotas, the following symptoms may be present. (1) Atistrava (excessive flow). (2) Atibaddha(less quantity or anurea), (3) Prakupita (with other chemical or microscopic substance like albumin, sugar, pus cells, RBC’s caste, bacteria etc.), (4) Alpalpam (frequent and small quantity of urine) and (5)Abhikshnam (frequency with small quantity) (6) Bahala(Concentrated) (7) Sashula (painful micturition). Above symptoms are found in the disease of urinary system out of them C.R.F.in one in which at times there may be very less quantity of urine output and in some there may be frequency of urine, mostly the urine is concentrated and Prakupita i.e. Albumin and caste are present. In urine some pus cells or R.B.C.’s are also found. Thus E.S.R.D. is a disease of Mutra-vaha srotas.

Line of Treatment

It may be understood clearly that this disease is Asadhya (incurable). Still as Acharyas have advised that, the treatment should be given up to the time the patient has the Prana (life), even in the throat; by the grace of God, the patient even with Arista (signs nearing a death), the patient may survive. The second reason is Ayurveda has got the great scope of treatment. Explain the prognosis clearly and then a physician should start the treatment. It is likely the patient may survive. The chances of survival are 50%, remaining patient die.

Patient that have undergone dialysis do not response well to treatment as patient can not adjust to the sudden rise in blood urea and creatinine.  So dialysis is to be done at short intervals repeatedly. The only treatment after dialysis is renal transplant.

Rasayana:

Rasayana means that line of treatment, which rejuvenates the cell of the body, increase resistance and immunity and also should be useful on the mutra-vaha srotas dushti, i.e. cure of disease. There are many Rasayana drugs of vegetables as well as Rasa (mercurial) origin. Generally Rasayana from vegetable origin should be selected to avoid accumulation or damage to the Liver or Kidney.

Though there is no harm in using Rasa preparation of such drugs, which acts as Rasayana as well as on srotas-in this case, on mutra-vaha srotas. Such drugs are (1) Gokshura (Tributes territories) (2) Shatavari (Asparagus recemoses), (3) Punarnava (Boarhevia diffusa), (4) Yastimadhu (Glycerrhiza glabra) etc. In Rasaushadhis (1) Chandrakala Rasa (2) Vasantkusumakar Rasa (3) Yogaraj (Charak Chi.16) etc. can be used safely.

Thus, my first prescription is milk processed. (1) with Shatavari and Gokshura one dose in the early morning. (2) As the disease is in Mutra-vaha srotas, Mala mutra and sweda should be properly excreted. For these mild diuretics like Punarnava, Trina-panchamoola etc. should be prescribed. For these mild diuretics, generally Dashamoola quath and Punarnavadi quath are used.
 
Even Ambu-vaha srotas are diseased; so (1) water processed with Gokshur should be given whenever patient thirsty. Over and above, there is likelihood of electrolyte imbalance; so Yavakshara with sugar should be given.

Primary disease if any should be treated. Some patients are suffering from Chhardi (vomiting) in the beginning. Vomiting may be the constant symptom. In such cases Chhardi ripu vati or Sutashekhar vati should be given three times a day. In same way Shanka bhasma may be given with lamon jouce and Ardrak swaras and Honey repeatedly after food.

Some patient have fever in the beginning, fever should be treated with Sudarshan Fant or Vati. Some patients may suffer from Diabetes mellitus, for them Darvyadi quath should be given. A question arises as to the relation or complication of the Diabetes mellitus. Acharya Charaka in Prameha Chikitsa says that if Apatarpana is given while treating Prameha may cause Gulma and Kshaya, Mehan Basti shoola, Mootra-graha suppression. In such cases Prameha should be treated along associated symptoms. The second thought also should be considered prameha, according to Ayurveda is the disease of Medo-dushti; Vrikka is mula of Medovaha srotas, thus medo dushti might be responsible for Renal failure in Madhumeha (Diabetes mellitus). 

Pathya-Apathya (DO’s and DON’Ts):

 One should avoid such foods, which may damage the kidney functions, they are seeds, red chillies and oils. They are likely to be damage the kidneys and mutra-vaha srotas. Salt or salt rich food should be avoided in such cases of oedema, but if oedema is not there, small amount of salt can be given. Light diet and easily digestible food can be given.

Yoga: Dhyana yoga is very necessary as it controls the blood pressure. Tranquilizing of mind and positive thinking are very necessary in all psychosomatic disorders.

Exercise: Mild, moderate indoor and outdoor exercises can be done. Over work, tension etc. should be avoided.  This much care should be taken. The treatment should last for about a year or so.

Conclusion:

 The description of mutrvaha-srotas dushti is given in many diseases but most important is, as described previously in Chhardi. In the description of asadhya Chhardi (incurable vomiting) Acharya Charaka says when purishavaha srotas (excretory system), mutra vaha srotas (urinary system), Swedo-vaha srotas (Channels of perspiration), Ambu-vaha srotas (Water balancing system) are obstructed by Vayu. The provoked obstructed doshas (non excreted material) are spreading or flowing in the whole body. These, when they come to koshtha (stomach), the produce vomiting, with specific odor and color as that of urine and fecal matter. They also produce thirst, breathlessness, hiccough et. The vomiting is dushta (vitiated) and ativega (sudden). This type of vomiting is incurable.  

Thus, these evidences proves vivid descriptions of E.S.R.D. in Ayurveda.

Referances:

1. Charak Samhita with Charak Chandrika Hindi Commentry; Dr.Bramhanand Tripathi, Dr.P.J.Deshpande, Vimaan Sthan Adhyaya 7, Varanasi; Chaukhmba Surbharati Prakashan, 1983.
2. Charak Samhita with Charak Chandrika Hindi Commentry; Dr.Bramhanand Tripathi, Dr.P.J.Deshpande, Chikitsa Sthana Adhyaya 20/16-17, Varanasi; Chaukhmba Surbharati Prakashan, 1983.
3. Charak Samhita with Charak Chandrika Hindi Commentry; Dr.Bramhanand Tripathi, Dr.P.J.Deshpande, Chikitsa Sthana Adyaya 16/81-86, Varanasi; Chaukhmba Surbharati Prakashan, 1983.
4. Dr. Nishant Shukla, Dr. C.P.Shukla – Critical Review and Ayurvedic approach of End Stage Renal Disease; Sachitra Ayurved, Jan.2007.