E-ISSN:2456-3110

Case Report

Renal Calculi

Journal of Ayurveda and Integrated Medical Sciences

2023 Volume 8 Number 10 October
Publisherwww.maharshicharaka.in

Clinical success story of Paneeya Kshara in the management of Renal Calculi - A Case Report

Padma1*, Masalekar S2
DOI:10.21760/jaims.8.10.39

1* Padma, Phd Scholar Associate Professor, Department Of Pg Studies In Shalyatantra, Sri Sri College Of Ayurvedic Science Research Hospital, Bengaluru, Karnataka, India.

2 Srinivas Masalekar, HOD Professor, Department of PG PhD studies in Shalyatantra, Government Ayurvedic Medical College, Bengaluru, Karnataka, India.

Kidney stones the urological disorder, with higher incidence attributed to modern lifestyle. The sharp excruciating pain, burning micturition, hematuria are the symptoms that disturbs the normal routine of the individual. Radiological investigations such as USG, KUB findings are necessary for diagnosis and to decide the therapeutic intervention. Challenges encountered in management are multifactorial etiology, the agonizing symptoms, lack of satisfactory curative measures and recurrence. Many individuals reluctant to undergo surgery or other invasive techniques and they approach Ayurveda for the better results. In Ayurveda, renal stones are diagnosed as Mutra Ashmari and a wide range of medicine and detailed treatment principles are advocated. Usage of Kshara is widely recommended by many scholars and treatise. Here a young man having symptomatic pelvi-ureteric junction stone, was treated using these principles and appreciated reduction in stone size radiologically and become clinically asymptomatic.

Keywords: Ashmari, Mahagada, Yava Kshara, Urolithiasis, Hydronephrosis

Corresponding Author How to Cite this Article To Browse
Padma, Phd Scholar Associate Professor, Department Of Pg Studies In Shalyatantra, Sri Sri College Of Ayurvedic Science Research Hospital, Bengaluru, Karnataka, India.
Email: 		Padma, Masalekar S, Clinical success story of Paneeya Kshara in the management of Renal Calculi - A Case Report. J Ayu Int Med Sci. 2023;8(10):247-251.
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https://jaims.in/jaims/article/view/2745

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-08-05 2023-08-10 2023-08-15 2023-08-21 2023-09-16
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None declared Nil Yes 20.54%

© 2023by Padma, Masalekar Sand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Introduction

Renal calculi, known for its agonizing pain and obstructive pathology. The symptoms such as pain, strangury, burning micturition, hematuria and fever experienced by the patient are not only affect his quality of life but also burden financially in terms of radiological investigations and expensive therapeutic interventions. Often the associated symptoms such as anorexia, nausea, vomiting, tachycardia may mask the diagnosis. In spite of accurate treatment, the stones may recur and challenge the physician. Further, the complications associated with calculi such as infection, hydronephrosis carry their own risk factors and even may end up in nephrectomy.[1] Thus many patients are looking for alternative approach as the remedial measure for renal stones.

Ayurveda, since many centuries is trying to address the sorrows of the human being in both preventive and curative way. Its principles of treatment are intended to remove the pathology along with its root cause. The renal calculi symptoms can be correlated to Mutrashmari in Ayurvedic parlance. Irregular diet habits, consumptions of food which is Sheeta, Snigdha, Guru and Madhura Rasa are the common etiology of Ashmari. They vitiate the Kapha and other Doshas and reach Basti Desha to produce Ashmari. There is striking similarities noticed in terms of symptoms such as Nabhi Basti Vedana, Mutradhara Sanga, Sarudhiramutrata, Aaavila Mutrata and Arochaka.[2] In treatment perspective, in-order to highlight the severity, Acharya Sushruta called it as ‘Antaka Pratima’ i.e., the God of death. He cautioned about enrooting the disease in early stage, or else end up in high risky surgical procedures.[3] He advised extensive use of Kshara as internal medication. There is a list of medicinal preparations which are meant to reduce the Dosha vitiation and repair the damages to kidney caused by stones.

Considering these guidelines, a case of renal calculi was treated using Yava Paneeya Kshara along with other medicines. The patient got improvement clinically, and follow up radiological showed significant reduction in the size of the kidney stones which is promising.

Clinical presentations

A 29-year-old unmarried male subject, visited

OPD on 31st October complained of pain in right flank region for 3 days, associated with burning micturition and vomiting. The pain was excruciating and disturbing his daily routine. Burning micturition was gradual in onset and had 6-8 times frequency per day. Vomiting was only once. There was no fever or hematuria noticed. He had similar history 1 year back and was then diagnosed with renal stones and took symptomatic treatment, details of which were not known to subject. His familial and psychosocial history were non-significant. Physical examinations were within normal limits except mild tenderness over right flank.

Investigations

USG abdomen and pelvis dated 28/10/22 showed a calculus of 8.7mm, in right proximal ureter, about 4 cm from the pelvi-ureteric junction causing back pressure changes in right kidney. The liver had incidental Grade 1 fatty changes. The renal function study was normal. Microscopically urine had Ph :6.5, Specific gravity: 1.025, RBC: Numerous, Pus cells:8-10 cells/HPF, Epithelial cells: 2-4 cells/HPF.

Therapeutic Intervention

Considering the symptoms and radiological findings, following treatment plan was adopted for initial 1 week.

Table 1: Showing initial prescription

SNMedicineFormDoseRoute of administration
1.Chandraprabha VatiTablet1-1-1/After foodOrally with water
2.Chandanasava + UsheerasavaLiquid15ml-0-15ml/After foodOrally with equal water
3.RenaliCapsule1-0-1/After foodOrally with water
4.Yava KsharaPowder1/4 tsp-0-1/4tsp/before foodOrally with honey
5.Vrikka Sanjeevini VatiTablet1-0-1/After foodOrally with water

Diet

1. Increase fluid intake including tender coconut water, sugar cane juice.
2. Include horse gram, Barley and banana stem in diet
3. Avoid spicy, oily and Maida products
4. To have meals on digestion of previous food

In first follow up after a week, patient was asymptomatic except slight discomfort at right flanks. Hence, same treatment was continued with repeat urine micro test on 16/11 which had following changes:

a) Pus cells : 2-4cells/HPF
b) Epithelial cells : 2-3 cell/HPF.


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Discussion

Renal calculi with its agonizing symptoms, expensive investigations, and complications not only disturbs the quality of life of the patient but also bring potential financial burden. For a consultant, high recurrence rate and rendering long term relief are the challenges. Though there are advanced modalities such as ESWL and PCNL, many time patients reach out Ayurvedic Vaidya just to avoid these procedures. It is the skill of the Vaidya to provide simple yet effective therapy with the back ground of ayurvedic principles.

Mutrashmari, the Ayurvedic parlance for renal calculi, is counted among the Ashta Mahagada (eight severe diseases) owing to its troublesome nature to patient and challenges faced by physician.[4] The treatment protocol suggested by Acharya Sushruta can be understood in two phases:

A. The initial phase - conservative mode. These can be further categorized into:

1. Medicines that are meant for Bhedana (breaking) of the Ashmari and expel it out.
2. Those which will repair renal parenchyma and render symptomatic relief.
3. Avoiding causative factors.

B. The second phase - surgical approach, where in urinary stones are manually extracted. Acharya Sushruta cautioned us to take informed consent from patient and permission from governing body, in order to be on safer side as success of this treatment is doubtful.[5]

The initial phase

Here, Acharya suggested different sets of medicines.

I. Bhedhana-
drugs such as Pashana Bheda, Gokshura, Yava, Kulattha, Shilajathu, Varunadi Gana, Chitraka etc. by virtue of Ushna, Teekshna Guna pacifies Kapha and thus acts upon Ashmari. Along with these herbs, Kshara of Tila, Apamarga, Kadali, Palasha and Yava, are advised for internal usage. Kshara does extensively Chedana, Bhedana, Darana actions and thus breaks the Ashmari. Here, Acharya has specified the dose of Paneeya Kshara as Karsha Matra (12gm) and Anupana as 2 Phala of Avi Mutra.[6]


II. Shothahara-
The formulations with Brihati, Kantakari, Trina Pancha Moola, Punarnava, and Guggulu, that acts on Shotha produced by Ashmari and reduces pain, burning sensation and other symptoms. These medicines also aid in healing the injury to renal parenchyma.

III. Avoiding causative factors-
A diet and regimen which inhibits the formation of Ashmari will ideally prevent the recurrence. Some general causative factors of Ashmari to be avoided as told by Acharya are, Divaswapna (day sleep), Samashana (eating both wholesome and unwholesome food together), Adhyashana (eating before digestion of previous meal), Snigdha (unctuous), Sheeta Veerya, Guru (heavy to digest) and Madhura (sweet) taste.[7] One can modify the dietary habits of the patient, and adopt regimens of opposite quality to causative factors to create unfavorable environment for kidney stones.

Bhedana of Ashmari was achieved using following Yogas:

1. Yava Kshara being easily available and targeted action on kidney stone was considered here. But by considering the Bala of the subject, the dose is reduced to 4gms /day in divided dose. The classical Anupana for Kshara is Avi Mutra. But procuring fresh Avi Mutra in urban set up for prolonged duration was a challenge. Also, its acceptance for oral administration by the patient was doubtful and thus may end up in discontinuing the therapy. Hence it was replaced by honey based on its Kaphahara, Lekhana, and Sukshma Marganusari properties.[8] It was making the Kshara palatable too, ensuring the adherence to the therapy.
2. Tablet Chandra Prabha Vati, with its chief ingredients - Ksharadwaya, Shilajatu and Guggulu is a well-known Ayurvedic formulation indicated in Ashmari, Mutrakrichra. It also reduced the pus cell count and infection. It was paused once normal urine microscopy results were achieved.[9] Capsule Renali, another preparation in the prescription, with Gokshuradi Guggulu[10] as its chief ingredient also aided in breaking the stone.
3. Sugar cane juice by virtue of diuretic property,[11] helped in expelling the calculi out of the body. Tender coconut water with its Snigda, Madhura and Sheeta Guna, gave the symptomatic relief. Its Basthi Shodhana[12] property aided in reducing Shotha. Kadali (banana stem) is


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advised by Acharya along with Kshara is also recommended to subject.
The next set of Yoga, probably rendered symptomatic relief and renal repair:
4. Chandanasava and Usheerasava helped in reliving burning micturition, a primary concern of the subject as they contain Chandana, Usheera, Priyangu, Padmaka, Manjista, Parpata[13] which pacifies Pitta.
5. Vrikka Sanjeevini Vati a composition of Gokshura, Guggulu, Pashanabheda, Varuna and Punarnava,[14] is acting on Shotha and there by repair the renal parenchyma.
As a measure to avoid recurrence,
A diet containing Barley and horse gram which are Ruksha, and Ushna Veerya[15] will act opposite to causative factors. This creates the renal environment unfavorable to formation of stones. Further, counselling about avoiding Adhyashana, Snigdha, Sheeta Veerya, Guru and Madhura Rasa act as preventive measure that is Nidana Parivarjana.
It is noteworthy that, the treatment went up to 45 days to establish a clinical and radiological resolution. From subject behalf, patience and adherence to the treatment and adopting to change in diet and regimen played a vital role. For a treating Vaidya, Yukthi in selecting formulations, modifying according to current need without compromising with basic principles turned as key to success. The efficacy of Kshara, even in minimal dose, when used with proper adjuvant is also noteworthy. It is evident by the asymptomatic phase during the treatment period and the CT KUB, picking the decreased size of the renal stone.
Thus, it can be recommended as useful guideline for OPD practice. There is a scope to reduce the duration of the treatment by increasing dose of Kshara, changing Anupana and by combining with different formulations. Academicians may consider to take clinical trial with larger sample size to create sufficient data in this regard. Hence adhering to ayurvedic principle of- ‘Swasthasya Swasthya Rakshanam Athurasya Vikara Prashamanam’.

References

1. Das S. A concise textbook of surgery. 6th edition. Kolkata: Dr S. Das; 2008. p. 1346.

2. Acharya YT, editor. Commentary Nibandha Sangraha of Dalhana on Susruta

Samhita of Acharya Susruta, Nidanasthana; Asmari nidanam adhyayam: Chapter 3, Verse 7.
Varanasi: Chaukambha Sanskrit sansthan; 2015. p. 277.

3. Acharya YT, editor. Commentary Nibandhaangraha of Dalhana on Susruta Samhita of Acharya Susruta, Chikitsasthana; Ashmari Chikitsitam Adhyayam: Chapter 7, Verse 3. Varanasi: Chaukambha Sanskrit sansthan; 2015. p. 435.

4. Acharya YT, editor. Commentary Nibandha Sangraha of Dalhana on Susruta Samhita of Acharya Susruta, Sutrasthana; Aavarneeyam Adhyayam: Chapter 33, Verse 4. Varanasi: Chaukambha Sanskrit sansthan; 2015. p. 144.

5. Acharya YT, editor. Commentary Nibandha Sangraha of Dalhana on Susruta Samhita of Acharya Susruta, Chikitsasthana; Ashmari Chikitsitam Adhyayam: Chapter 7, Verse 29. Varanasi: Chaukambha Sanskrit Sansthan; 2015. p. 436.

6. Acharya YT, editor. Commentary Nibandha Sangraha of Dalhana on Susruta Samhita of Acharya Susruta, Chikitsasthana; Ashmari Chikitsitam Adhyayam: Chapter 7, Verse 22. Varanasi: Chaukambha Sanskrit Sansthan; 2015. p. 436.

7. Acharya YT, editor. Commentary Nibandha Sangraha of Dalhana on Susruta Samhita of Acharya Susruta, Nidana sthana; Ashmari nidanam adhyayam: Chapter 3, Verse 11. Varanasi: Chaukambha Sanskrit Sansthan; 2015. p. 278.

8. Acharya YT, editor. Commentary Nibandha Sangraha of Dalhana on Susruta Samhita of Acharya Susruta, Sutrasthana; Dravadravyavidhim Adhyayam: Chapter 45, Verse 132. Varanasi: Chaukamba Sanskrit Sansthan; 2015. p. 207.

9. Jagani P, Moharana P, Soumya EA. A Critical Review on Chandraprabha Vati - An Ayurvedic Formulation. J Ayurveda Integr Med Sci. 2022;11:136-144.

10. Shah AB, Mohod P, Deep VC, Sharma GK. Mutrashmari (Urolithiasis): A case successfully treated with Gokshuradi Guggulu. Int J of Ayurveda Pharma Res. 2020;8(3):76-78.

11. Acharya YT, editor.


J Ayu Int Med Sci 2023;8(10)250
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Commentary Nibandha Sangraha of Dalhana on Susruta Samhita of Acharya Susruta, Sutra sthana; Dravadravyavidhim adhyayam: Chapter 45, Verse 148. Varanasi: Chaukambha Sanskrit sansthan; 2015. p. 208.

12. Acharya YT, editor. Commentary Nibandha Sangraha of Dalhana on Susruta Samhita of Acharya Susruta, Sutra sthana; Dravadravyavidhim adhyayam: Chapter 45, Verse
43. Varanasi: Chaukambha Sanskrit sansthan; 2015. p. 200.

13. Goel KN, Singh RH. Clinical Trial of Chandanasava, in the treatment of urinary tract infection. Anc. Sci. Life. 1991 April;10(4):248-252.

14. Pooja Verma A, Lal V.K. Punarnava - a natural remedy by ayurveda. Int J Pharm Sci. 2014 August;6(8):1-6.

15. MC Shobhana, Medha Kulkarni. Kulatha: Therapeutic Approach-A Comprehensive Review. Int J Ayurveda Pharma Res. 2017;5(4):89-93.


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