Abstract: As per the global burden of disease, chronic kidney disease (CKD) is the 12th leading cause of death worldwide. Relevant screening, diagnosis, and management by primary care clinicians are necessary to prevent adverse CKD-associated outcomes, including cardiovascular disease, end-stage kidney disease, and death. India is day by day progressing in this field so we need to find Alternative treatment apart from dialysis here we come with a scope of homoeopathy.
Keywords: CKD, GFR, MANAGEMENT CKD, HOMOEOPATHIC CASE STUDY, EFFECT OF CONSTITUTIONAL MEDICINE
Abbreviations: chronic kidney disease (CKD), glomerular filtration rate (GFR), non-steroidal anti-inflammatory drugs (NSAIDS), example (eg), end-stage kidney disease (ESKD), human immunodeficiency virus (HIV), albumin-to-creatinine ratio (ACR), kidney disease improving global outcomes (KDIGO) criteria
Introduction: CKD is defined as a constant anomaly in kidney structure or function (eg, glomerular filtration rate [GFR] <60 mL/min/1.73 m2 or albuminuria ≥30 mg per 24 an increased risk of cardiovascular disease and chronic renal failure [1].
Relevance: Chronic kidney disease (CKD) influence between 8% and 16% of the population worldwide. It is defined by a glomerular filtration rate (GFR) less than 60 mL/min/1.73 m2, albuminuria of at least 30 mg per 24 hours, or markers of renal damage (eg, hematuria or structural deformity such as polycystic kidney disease or dysplastic kidneys) remaining for more than 3 months [2]. CKD is more prevalent in low- and middle-income than in high-income countries [3]. Globally, CKD is most commonly attributed to hypertension and/or diabetes, but other causes such as infection, glomerulonephritis and environmental exposures such as air pollution and pesticides are common in Asia, sub-Saharan Africa, and many developing countries. Genetic factors contribute to CKD risk [4]. Examples are sickle cell trait and the presence of 2 APOL1 risk alleles, both common in people of African ancestry but not European ancestry that may double the risk of CKD [5].
Early detection and treatment by clinicians are important as progressive CKD is associated with an adverse clinical outcome, which includes end-stage kidney disease (ESKD), cardiovascular disease, and increased mortality.
Risk factors : Diabetes, hypertension, autoimmune diseases, systemic infections (eg, HIV, hepatitis B virus, hepatitis C virus), nephrotoxic medications (eg, nonsteroidal anti-inflammatory drugs, herbal remedies, lithium), kidney stones, urinary tract obstruction, malignancy, recurrent urinary tract infections, obesity, reduced kidney mass (eg, nephrectomy, low birth weight), history of acute kidney injury, smoking, intravenous drug use (eg, heroin, cocaine), sociodemographic, family history of kidney disease, age >60 years, nonwhite race, low income, low education, genetic (apol1 risk alleles, sickle cell trait and disease), polycystic kidney disease, alport syndrome, congenital anomalies of the kidney and urinary tract, and other familial causes[1].
Staging: Once diagnosis of CKD is made, the next step is to determine its stage, which is based on GFR, albuminuria, and cause of CKD. Staging of glomerulus filtration rate is classified as G1 (GFR ≥90 mL/min/1.73 m2), G2 (GFR 60–89 mL/min/1.73 m2), G3a (45–59 mL/min/1.73 m2), G3b (30–44 mL/min/1.73 m2), G4 (15–29 mL/min/1.73 m2), and G5 (<15 mL/min/1.73 m2) [2]. Laboratories routinely report the estimated GFR (eGFR) based on filtration markers. The most routinely used filtration marker is creatinine, a 113 Dalton byproduct of creatine metabolism. The preferred estimating value for is eGFR values greater than 60 mL/min/1.73 m2.
Diagnosis: for diagnosis certain tests are needed.
- Blood tests: urea, creatinine, electrolytes
- Urine tests: Analysing urine sample can reveal abnormalities that can help identify the cause of chronic kidney disease.
- Imaging test: it helps in accessing size and structure of kidney.
- Kidney biopsy: for finding cause of problem [1].
Screening for CKD: The National Kidney Foundation has formulated a kidney profile test that includes quantification of both serum creatinine for estimating GFR and urine ACR. A risk-based group approach to screening is suggested by many clinical practitioner guidelines, with screening suggested in those who are older than 60 years or with a history of diabetes or hypertension. Screening should also be reviewed in those with clinical risk factors, including obesity, autoimmune disease, recurrent urinary tract infections, kidney stones, reduced kidney mass, exposure to certain medications such as NSAIDs or lithium, or have prior episodes of acute kidney injury, among others. However, no randomised clinical trials have illustrated that screening asymptomatic patients for CKD improves outcomes [8].
Case: A patient, 54 years old person, presented on 17th April 2021 with complaints of generalised swelling more on both legs and face for 7 months. The patient was too weak and prostrated. He was also having breathing difficulty. Patient was hypertensive and used to take modern medicine. Patient had no significant past history other than typhoid and family history was also not significant. He was on dialysis thrice a week under a nephrologist.
History of present complains: He was suffering from CKD since past 7 years approximately. Urine’s quantity and flow was reduced.
Physical general- Appetite has decreased, thirst was moderate, tongue was clean, stool was constipated, sweat was moderate, sleep was disturbed, due to restlessness in legs.
Mental general- restlessness, anxiety about his health, talks of business, wants to go to his office, boaster
Observations and findings
Physical examination- appearance- anxious look, blood pressure- 146/92 mm of hg pulse-78 per minute, regular, respiration –12 per minute, pallor- +++, jaundice– absent, clubbing – absent, tremor- not significant, neck vein- not engorged, general survey- face- puffiness of the face, oedema- pitting oedema present, skin- no scabies or pyoderma present.
Inspection- no any swelling is in the genital.
Palpation- no, scrotal swelling-no, phimosis- no contact ulcer in genitalia, no tenderness in the renal angle.
Percussion- no liver dullness, dullness on percussion of urinary bladder, Auscultation- no renal arterybruit was present, cardiovascular system- neck vein not engorged, apex beat is in left 5th intercostal space ½ inch inside the mid-clavicular line, no murmur heard, no pericardial rub, S1 and S2 audible, no sign of pericardial effusion.
| Date | Serum urea (mg/dl) | Serum creatinine (mg/dl) |
| 18/1/2021 | 68.4 | 6.92 |
| 27/6/21 | 179 | 4.4 |
| 28/9/21 | 120.4 | 6.21 |
| 15/10/21 | 107.84 | 6.93 |
| 30/10/21 | 122.5 | 6.6 |
| 11/11/21 | 115.3 | 6.22 |
| 11/12/21 | 95.2 | 5.35 |
| 3/1/22 | 107.4 | 5.35 |
| 23/1/22 | 120.5 | 7.5 |
| 27/1/22 | 93.7 | 6.09 |
| 3/2/22 | 90.7 | 5.88 |
| 17/1/22 | 125.6 | 6.44 |
| 20/3/22 | 75.4 | 5.28 |
| 5/4/22 | 92.4 | 6.15 |
Investigation- examination of blood biochemistry (Table 1)
FOLLOW UP: As per the symptomatic improvement (Table 2)
| Date | Generalised swelling | Weakness | Breathing difficulty | Prescription | Blood pressure |
| 27/6/21 | Gradually diminished | Persist | Gradually diminished | Sulphur 200 | 130/92 |
| 15/10/21 | Diminished | Persist | Diminished | Sulphur 200 | 140/80 |
| 30/10/21 | Very much diminished | Improved | Very much improved. | Saccharum lactis 200 | 130/84 |
| 11/12/21 | No more swelling | Improved | No more breathing difficulty. | Sulphur 200 | 124/82 |
| 3/1/22 | No | Improved | No difficulty | Saccharum lactis | 130/78 |
| 23/1/22 | No | Improved | No difficulty | Saccharum lactis | 136/76 |
| 27/1/22 | No | Improved | No difficulty | Saccharum lactis | 134/80 |
| 4/2/22 | No | Improved | No difficulty | Saccharum lactis | 120/82 |
| 20/3/22 | No | Little increased | Heaviness felt while breathing | Sulphur 1m | 146/94 |
| 5/4/22 | No | Improved | No difficulty[U1] [U2] | Saccharum lactis | 128/76 |
Details of homoeopathic prescription of Sulphur 200 and its follow ups
Analysis and evaluation of symptoms:
| Sr. No. | Symptom | Type | Intensity | Common/Uncommon |
| 1 | SKIN-ITCHING | PARTICULAR GENERAL | 2nd grade | Common |
| 2 | KIDNEY-RENAL FAILURE-CHRONIC | PARTICULAR GENERAL | 3rd grade | Common |
| 3 | SKIN- ERUPTIONS | PARTICULAR GENERAL | 1st grade | Common |
| 4 | SKIN-ERUPTIONS -PUSTULES | PARTICULAR GENERAL | 1st grade | Common |
| 5 | STOMACH-NAUSEA | PARTICULAR GENERAL | 1st grade | Common |
| 6 | SLEEP-SLEEPLESSNESS | M e n t a l Generals | 1st grade | Common |
| 7 | STOMACH-APPETITE-DIMINISHED | PARTICULAR GENERAL | 1st grade | Common |
| 8 | MIND-SUICIDAL DISPOSITION | M e n t a l Generals | 2nd grade | Common |
| 9 | GENERAL-HYPERTENSION | physical Generals | 1st grade | Common |
| 10 | GENERAL-DIABETES MELLITUS | Physical GENERAL | 1stgrade | Common |
| 11 | GENERALS-FOOD AND DRINKS-SWEETS-DESIRE | PARTICULAR GENERAL | 1stgrade | Common |
| 12 | MIND-ANXIETY-HEALTH ABOUT-OWN HEALTH;ONE’S | MENTAL PARTICULAR | 3rd. grade | Common |
| 13 | MIND-BUSINESS-DESIRE FOR | MENTAL PARTICULAR | 3rd. grade | Uncommon |
| 14 | SKIN-ITCHING-NIGHT | PARTICULAR GENERAL | 1stgrade | Common |
| 15 | GENERAL-WEAKNESS | PARTICULAR GENERAL | 1stgrade | Common |
| 16 | MIND-IRRITABILTY | M e n t a l Generals | 1stgrade | Common |
| 17 | GENERAL-ANEMIA | PARTICULAR GENERAL | 1stgrade | Common |
| 18 | MIND-BOASTER | M e n t a l Generals | Uncommon | |
| 19 | MIND-RESTLESSNESS | M e n t a l Generals | 1stgrade | Common |
| 20 | GENERAL-HEAT-SENSATION OF | PARTICULAR GENERAL | 1stgrade | Common |
Reportorial results:
The chief remedies for this case include Sulphur, Arsenicum album and Lachesis mutus.
The remedy which was prescribed was Sulphur 200.
As Sulphur achieved the maximum marks and there was complete loss of appetite, weight-like pressure on abdomen, talks about business, boasting of his accomplishments which was much more prominent in Sulphur than any other remedy.
Followed by Saccharum lactis, he needed only just 2 dialysis needed from past 1.5 years as per reports and he was currently taking allopathic medicine for hypertension only.
Remedy was selected on the basis of RADAR 10 from Schroyens F. Synthesis Repertory.
Monitoring: Management of CKD includes cardiovascular risk reduction, blood pressure treatment of albuminuria and avoidance of potential nephrotoxins (eg, NSAIDS). Patients also need monitoring for complications of CKD, such as hyperkalaemia, metabolic acidosis, hyperphosphataemia, vitamin D deficiency, secondary hyperparathyroidism, and anaemia.
Dietary measure:
As per KDIGO guidelines, recommended protein intake should be reduced to less than 0.8 g/kg per day (with proper education) in adults with CKD stages G4-G5 and to less than 1.3 g/kg per day in adult patients with CKD at risk of progression. Possible benefits of dietary protein restriction should be equalised with the concern of precipitating malnutrition and/or protein wasting syndrome. Low dietary acid loads (eg, more fruits and vegetables and less meats, eggs, and cheese) can also help protect against kidney injury. Low-sodium diets (generally <2 g per day) are advised for patients with hypertension, proteinuria, or fluid overload [2].
Conclusion:
Chronic kidney disease affects around 12% of the population worldwide and is one of a leading cause of death. Optimal management of CKD includes treatment of albuminuria, cardiovascular risk reduction, avoidance of potential nephrotoxins, and adjustments to drug dosing. Patients also requires continuous monitoring for its complications of CKD, such as hyperkalaemia, anaemia, metabolic acidosis and other metabolic abnormalities. Diagnosis, staging, and appropriate treatment is important in reducing the burden of CKD worldwide.
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About the Author:
Dr Naman Garg
Md Hom Scholar, Guru Mishri Homoeopathic Medical College, Jalna
