Breaking the dependency cycle: A case report on successfully managed hemodialysis dependent chronic kidney disease with Ayurvedic treatment

Abstract

Chronic Kidney Disease (CKD) affects 13.4 % of the global population. Patients with End-Stage Renal Disease (ESRD) needing kidney transplant surgery are estimated between 4.902 and 7.083 million globally as of 2019 in India, which remains unaffordable for most of the population. This case study highlights a CKD G5 male patient undergoing hemodialysis weekly twice for two months, previously advised for transplant. The patient approached P D Patel Ayurveda Hospital, Nadiad, India, for treatment. Presented with puffiness on the face, breathlessness, muscle cramps, appetite loss, bilateral pedal edema, and occasional nausea and vomiting. Before Ayurvedic treatment, his serum creatinine level remained 12 mg/dL even with hemodialysis twice a week, which has been reduced up to 2.1 mg/dL, and blood urea reduced significantly, hemoglobin increased from 9.7 gms% to 14 gms%, and eGFR increased from 5 mL/min per 1.73 m² to 34.8 mL/min per 1.73 m². After the treatment, the patient is asymptomatic. This improvement is stable even after discontinuing all the medications except antihypertensive for two years. Following the treatment, dialysis was completely stopped, and the patient no longer required hemodialysis or a kidney transplant. This case provides new insight into the potential of traditional Ayurvedic treatments to manage advanced CKD, offering a cost-effective alternative to dialysis and transplantation.

1. Introduction

CKD is characterized by disrupted kidney function for more than 3 months or in other terms, it is defined as a kidney condition with glomerular filtration rate (GFR) < 60 mL/min per 1.73 m² [1]. CKD refers to an irreversible deterioration in renal function. Reduced kidney function initially manifests as a biochemical abnormality, but eventually, it causes loss of excretory, metabolic, and endocrine functions of the kidney, leading to clinical symptoms and signs of renal failure. CKD can also cause other illnesses like breathlessness, nausea, anorexia, etc. When kidney function declines below a certain point over weeks, months, or years, leading to end-stage renal disease, which is called kidney failure [2]. Management of ESRD, which includes hemodialysis and kidney transplants, is not affordable for the majority of the patients in India because of poor socioeconomic conditions. Recent studies indicate that Ayurvedic treatment can significantly decelerate disease progression in patients with advanced CKD [3,4].

1.1. Impact of CKD on the patient

Symptoms and complications cause disturbances in routine life. Psychological distress, including anxiety and depression, is common. Hemodialysis dependency leads to frequent hospital visits and treatment sessions, impacting daily activities and quality of life. Financial burden and affordability issues in countries like India may limit access to treatment and contribute to patient distress.

1.2. Impact of CKD on the healthcare system

CKD imposes a substantial financial burden on healthcare systems due to the complexity and long-term nature of the treatment. The global burden of CKD is significant, affecting 13.4 % (11.7–15.1 %) of the population. An estimated 4.9 to 7.1 million patients with ESRD require kidney transplants globally [5]. However, only 80,000 to 90,000 transplants are performed annually as of 2019. In India, CKD prevalence ranges from 9 % to 13 %, with approximately 200,000 to 300,000 patients requiring kidney transplants annually, while only 7000 to 8000 are conducted. Additionally, over 175,000 patients in India are on long-term hemodialysis, with nearly 34,000 new patients starting dialysis each year.

The need for multidisciplinary care leads to resource allocation challenges, as CKD patients often require coordinated management across various specialties. CKD also presents significant public health concerns, emphasizing the necessity for comprehensive prevention and management strategies. Hemodialysis-dependent patients place additional strain on healthcare resources, requiring specialized care facilities and equipment. Furthermore, limitations of hemodialysis and kidney transplantation, including the lifelong nature of treatment and associated high costs, complicate healthcare delivery. Even after surgical interventions like kidney transplants, the risk of disease recurrence necessitates ongoing monitoring and care, further stretching system capacities. Hemodialysis is a life-sustaining treatment for patients with end-stage renal disease.

1.3. Challenges of hemodialysis-dependent CKD

Hemodialysis is typically required several times a week and lasts for several hours each session, which can be burdensome for patients and disrupt their daily living. Long-term hemodialysis requires a suitable access site for the blood to be removed and returned during hemodialysis. Creating and maintaining vascular access, such as arteriovenous fistulas or grafts, can pose risks of infection, thrombosis, and other complications. Hemodialysis patients are at an increased risk of infections, particularly bloodstream infections associated with vascular access sites or peritoneal catheters in peritoneal hemodialysis. These infections can be severe and may require hospitalization and antibiotic therapy. Patients who are on hemodialysis have a higher risk of cardiovascular disease, including heart attacks, heart failure, and stroke. The hemodynamic changes during hemodialysis sessions, electrolyte imbalances, and accumulation of uremic toxins can contribute to cardiovascular complications. Prolonged hemodialysis treatment may lead to further deterioration of residual kidney function, reducing the effectiveness of hemodialysis and increasing the risk of complications.

CKD cannot be correlated directly to any disease in Ayurveda. According to Ayurveda principles, CKD is a disease of Mootravahasrotasa (The channel system responsible for the formation, storage, and excretion of urine) [6]. Morbid changes in these srotas (Channels of circulation), due to the accumulation or impact of aggravated doshas can lead to obstruction and reduced kidney functions like filtration, reabsorption, and secretion, depending on the involvement of glomeruli or renal tubules.

2. Patient information

On April 1, 2022, a 40-year-old male patient, married, working as a driver, came to P D Patel Ayurveda Hospital, Nadiad, India. He was diagnosed with hypertension 5 years ago, and his systolic blood pressure remained more than 200 mmHg and diastolic pressure more than 100 mmHg constantly, even after consuming antihypertensive drugs regularly (Clonidine 100mcg, 2tabs TDS, Nifedipine 20mg, 2tabs TDS). He was relatively healthy 2 years before coming to this hospital, then he started nausea and vomiting, for which he visited the nearby hospital and was diagnosed with CKD. After that, he experienced abdominal pain and breathlessness and was admitted to a conventional medical hospital but did not get relief however, he also started to have bilateral pedal edema and puffiness on his face as well as his blood oxygen levels also started to drop, and shifted to another conventional medical hospital having nephrology unit where hemodialysis was started. He had undergone 7 cycles of hemodialysis in 11 days after which he was discharged from that hospital but did not get relief in signs and symptoms satisfactorily. Hence he was admitted to another hospital where again he had undergone another 5 cycles of hemodialysis. Upon discharge from there, he was advised to continue hemodialysis twice a week throughout his life. He had undergone hemodialysis 30 times before he came to P D Patel Ayurveda Hospital. His creatinine was reaching more than 12mg/dL after 3 days of hemodialysis every time, as well as the patient, was having all the above-mentioned signs and symptoms even after performing hemodialysis twice a week regularly. Hence, he was advised for kidney transplant surgery by a nephrologist which is costly and he was unable to afford it due to poor socioeconomic condition.

3. Clinical findings (on admission)

• •Puffiness on the face (since past 2 months)
• •B/L pedal pitting edema (since past 6 months)
• •Breathlessness on exertion (since past 6 months)
• •Occasional muscle cramps (since past 6 months)
• •Loss of appetite (since past 1 year)
• •Occasional nausea and vomiting (since the past 1 year)

Findings of physical examination on rest (April 01, 2022).

• •BP – 210/110 mmHg
• •Pulse – 82/min
• •SpO₂ – 98 %
• •General examination: B/L pedal pitting edema, puffiness on the face.
• •Respiratory examination: B/L fine crackles heard.

4. Diagnostic assessments

Laboratory findings as of April 01, 2022.

• •Hb – 9.7 (gms%)
• •Urine albumin – Trace
• •Urine sugar – 3+
• •Blood urea – 99.0 (mgm%)
• •Serum creatinine – 11.3 (mg/dL)
• •eGFR – 5 (mL/min/1.73m²) (Calculated using MDRD formula)
• •Na⁺ – 129.0 (mmol/L)
• •K⁺ – 5.2 (mmol/L)
• •Cl⁻ – 98.0 (mmol/L)
• •Ca⁺⁺ – 9.0 (mmol/L)

A renal color doppler was performed on February 11, 2022. The investigations revealed that the right kidney measured 10.7 × 4.3 cm, while the left kidney measured 11.1 x 5.0 cm. Both kidneys exhibited increased echotexture bilaterally, with partial loss of cortical medullary differentiation. Additionally, mild dilatation was noted in the Inferior Vena Cava (IVC), which measured 2.13 cm, along with dilation of the hepatic veins. Furthermore, moderate pleural effusion was observed bilaterally.

The initial urine sugar level of 3+ raised concern for diabetes; however, the patient's random blood sugar was 112 mg/dL, within normal limits, and subsequent urine sugar tests showed a consistent decline without specific antidiabetic interventions. In CKD patients, the renal threshold for glucose can be altered, leading to glycosuria even without significant hyperglycemia [7].

The diagnosis of CKD stage G5 was established based on calculated eGFR (5 mL/min per 1.73 m²) and persistently elevated serum creatinine levels (>12 mg/dL) despite regular dialysis, along with a prolonged history of hypertension and chronic symptoms. AKI (Acute Kidney Injury) was ruled out due to the chronic nature of the condition.

5. Timeline

Table 1. Represents the timeline of the occurrence of events in the present case study. It represents all the symptoms along with the previous history of the patient and the results obtained.

Table 1.

Timeline of clinical events.

Time	Condition
April 2020	Patient experienced occasional nausea and vomiting, leading to a diagnosis of CKD at a nearby hospital.
January 2022	Symptoms got worsen, including abdominal pain and breathlessness, leading to hospitalization and initiation of hemodialysis. In january 2022, patient underwent a total of 7 hemodialysis sessions during the hospital stay.
February 2022	Despite treatment, symptoms persist, and patient undergone 5 additional hemodialysis sessions during re-admission to another hospital.
March2022	Discharged with advice of twice-weekly hemodialysis and consideration for kidney transplant surgery due to persistently high creatinine levels (>12mg/dL).
The patient came to P.D Patel Ayurveda hospital, Nadiad.
April 1, 2022	40-year-old male driver with a history of hypertension, presents to the outpatient department with complaints of puffiness on face since last 2 months, breathlessness since last 6 months, Muscle cramps since last 6 months, loss of appetite since last 1 year, B/L pedal pitting edema since last 6 months, nausea and vomiting occasionally since last 1 year, blood pressure: 210/110 mmHg (constantly uncontrolled elevated blood pressure), pulse: 82/min, spo2: 98 %, serum creatinine: 11.3mg/dL (April 01, 2022 at the time of admission), Urine output: 400ml/24hrs
April 1, 2022–May 11, 2022. During his hospitalization From	Before he got admitted to our hospital he had undergone hemodialysis 2 times/week, and after 3rd day of each hemodialysis his creatinine level remained more than 12mg/dL along with all clinical signs and symptoms, during his hospital stay he had undergone hemodialysis twice, 1st hemodialysis on 7th day, 2nd hemodialysis was on 21st day of hospitalization, after which there is no need of hemodialysis till date.
May 11, 2022 On discharge from the hospital	After 1 month 12 days of treatment in IPD he shows significant relieve in his signs & symptoms and his serum creatinine levels, urine sugar and blood urea is also significantly reduced and eGFR & hemoglobin were improved. On the date of discharge his serum creatinine levels were 4.9mg/dL and eGFR at 14 mL/min.
August 06, 2022 (3 months followup)	Patient is asymptomatic on followup. Further improvement in renal function, his eGFR improved to 28 mL/min/1.73m2,
February 03, 2023 (6 months followup)	Continued improvement in renal function, He himself discontinued all these medicines except antihypertensive medicines after this followup.
January 13, 2024 (1 years after discontinued all medicines except antihypertensive himself.	During his routine investigations his creatinine levels were 2.79 mg/dL, Without any complaints. He has regained his quality of life, returning to work without the burden of hemodialysis.
December 10, 2024 2 years after discontinued all medicines except antihypertensive himself.	His creatinine levels were 2.1 mg/dL and eGFR 34.8 mL/min/1.73m2 without any symptoms and is continuing his daily activities and work without any discomfort.

6. Treatment schedule

The treatment schedule during hospitalization is given in Table 2, the doses of the continuous antihypertensive drugs of the patient were not interfered.

Table 2.

Treatment schedule during hospitalization.

Sr.no	Name	Dose	Time	Anupana
1.	Nadi svedana at lower back – with Nirgundi leaves	As per samyak lakshana	Morning (before Niruha basti)	–
2.	Niruha basti – Punarnavadi kvatha	320ml	Morning (Empty stomach)	–
3.	Nasya – Brahmi ghruta	8″- 8” Drops	Evening	–
4.	Varunadi kwatha	40ml	2 times (empty stomach)	–
5.	Gokshuradi guggulu	1 gm	3 times (after food)	With hot water
6.	Rasayana churna	2 gms	2 times,	With hot water
	Bhumyamalaki churna	3 gms	Morning-evening
7.	Svadamstra rasayana	500 mgs	2 times, Morning-evening	With hot water
8.	Kantaphalabhra rasa	250 mgs	2 times, Morning-evening	Sublingually
9.	Tab uricare Contents- extracts of Crataeva nurvala (80 mg), Boerhavia diffusa (80 mg), Tinospora cordifolia (80 mg), Shuddha Shilajit (80 mg) and Shuddha guggulu (80 mg) was supplied from petlad mahal arogya mandal pharmacy, Nadiad, Gujarat.	500 mgs	3 times, Morning-afternoon-evening	With hot water

During the IPD period, every day, Nadi svedana (fomentation therapy) on the lower back was performed in the morning till Samyak svedana lakshana (signs of adequate fomentation therapy) was achieved. Niruha basti with Punarnavadi kwath 320ml was given on an empty stomach, followed by Nadi svedana. Nasya karma was performed in the evening with 8-8 drops of Brahmi ghrita (medicated ghee prepared with Bacopa monnieri). The following oral medicaments were administered during the IPD period and continued post-discharge from the hospital. Varunadi kvatha administered at a dosage of 40ml twice daily on an empty stomach, Gokshuradi guggulu 1 gms thrice daily after meals with water, Rasayana churna (2 gms) combined with Bhumyamalaki churna (3 gms) twice daily with water, Svadamstra rasayana 500 mgs tablets twice daily with water, Kantaphalabhra rasa 250mg tablets twice daily sublingually, and Tab Uricare 500 mgs thrice daily with water. A strict diet was followed during the IPD period and continued post-discharge from the hospital.

6.1. Diet & Restrictions

The dietary plan included Pathya ahara (a wholesome diet consumed by the patient), for breakfast, the recommended meal consisted of 20 g of Chyavanprasha avaleha consumed with 100 ml of boiled cow milk. Lunch included boiled moong (green gram), moong bean soup, cooked vegetables, and rice. For dinner, moong bean soup accompanied by rice or khichadi along with cooked vegetables was given. A maximum of 150 ml of cow milk per day was allowed but was ensured that it should not be consumed alongside any of the aforementioned food items.

Apathya ahara (diet to be avoided) excessive salt intake, deep-fried foods, spicy dishes, heavy-to-digest food items, cheese, paneer, fermented foods, all millets except rice, and sour-tasting foods were avoided. All items other than those mentioned above were also restricted and the patient was on monthly follow-up appointments.

6.2. Tolerability and safety

We monitored the patient's tolerability to the treatment regimen closely. Throughout the course of treatment, the patient reported no adverse effects or discomfort, allowing for consistent adherence to the prescribed therapies.

7. Followup and outcomes

The outcome of this case reveals significant improvements in the patient's signs and symptoms. Before treatment, the patient presented with severe bilateral pedal edema, which resolved completely post-treatment. General weakness was noted as severe initially, but after treatment, the patient reported no weakness. Loss of appetite, initially severe, improved to a good appetite, and symptoms of nausea and vomiting, which were moderate before treatment, were absent afterward. Additionally, breathlessness decreased from moderate to absent, and muscle cramps, initially reported as moderate, also got resolved. These findings indicate a marked enhancement in the patient's overall health status following the intervention. The changes in serum creatinine levels are mentioned in Fig. 1. And all the laboratory investigations during hospitalization and on follow-up are mentioned in Table 3.

Fig. 1.

Serum creatinine levels.

Table 3.

Laboratory investigations during hospitalization and on followup.

Date	April 01, 2022	April 08, 2022	April 19, 2022	May 11, 2022	August 06, 2022	February 03, 2023	January 13, 2024	December 10, 2024
Hb (gms%)	9.7	9.7	9.6	10.1	12.2	12.3	14.9	14
Urine albumin	Trace	+	Trace	Trace	Trace	Trace	Nil	Nil
Urine sugar	3+	2+	Trace	Nil	Nil	Nil	Nil	Nil
Blood urea (mgm%)	99.0	98.0	87.0	51.0	37.0	38.0	45.0	42.0
Serum creatinine (mg/dL)	11.3	11.2	7.7	4.9	2.8	2.3	2.79	2.1
eGFR mL/min/1.73m2	5	5	8	14	28	28	28	34.8
Na+ (mmol/L)	129.0	123.0	140.0	135.0	142.0	142.0	138.0	139
K+ (mmol/L)	5.2	4.6	4.3	4.4	4.7	4.3	4.2	4.6
Cl− (mmol/L)	98.0	96.0	100.0	98.0	108.0	111.0	106.0	110.0
Ca++ (mmol/L)	9.0	9.0	8.9	8.9	8.9	8.8	8.9	8.7

The patient showed prominent improvement after Ayurvedic interventions and diet modifications, reducing need of hemodialysis from twice a week to zero cycles of hemodialysis.

After 1 month and 12 days of treatment in the IPD, he shows significant relief in his signs & symptoms, and his serum creatinine levels and blood urea are also significantly reduced, and eGFR & hemoglobin were improved.

On discharge, the patient was advised to continue oral medicines with a strict diet at home and come regularly for follow-up on every 28th day, on May 11, 2022, when he got discharged his serum creatinine levels were 4.9 mg/dL and eGFR was 14 mL/min/1.73 m², he had continued oral medicines at home with a strict diet, on his 3rd followup on August 06, 2022 his creatinine levels were 2.8 mg/dL and eGFR improved to 28 mL/min/1.73 m², after which he had further continued oral medicines, and on February 03, 2023 (6th followup) his creatinine levels were 2.3mg/dL after which he himself discontinued all these medicines except antihypertensive medicines and on January 13, 2024 (11 months after stopping all medicines) during his visit for routine investigations his serum creatinine levels were 2.79 mg/dL, Now as on December 10, 2024 his serum creatinine levels were 2.1 mg/dL even after stopping all medicines except antihypertensive for two years.

His hemoglobin levels were significantly improved from 9.7 gms% to 14 gms%, urine albumin from 'Trace' to 'Nil', and urine sugar levels were monitored throughout the treatment course, showing a progressive decline from 3+ on April 1st, 2022, to nil by December 13th, 2024 (Table 3). Random blood sugar on April 1st, 2022, was 112 mg/dL, and blood urea was 99 mgm% now, it has come down to random sugar value not added 42 mgm%, and his electrolyte levels were maintained throughout the treatment.

Besides all these laboratory findings, the patient does not have any signs and symptoms and his quality of life is restored, which was impaired earlier when he was on hemodialysis. Now he got back to his driving work without having any issues.

After 1 month and 12 days of treatment in the IPD and taking regular medicines, he now gets complete relief in edema, his appetite is good, breathlessness, nausea, and vomiting are absent, and his serum creatinine level is 2.1mg/dL, blood urea is significantly reduced, and eGFR is improved without the need of kidney transplant surgery or renal replacement therapy.

8. Discussion

CKD does not precisely correlate with any single disease condition described in classical Ayurvedic texts.

The pathophysiology of CKD can be understood through a progressive chain of pathological events based on Ayurvedic principles. According to Ayurveda, CKD is categorized as a disorder of the mootravaha srotas and is considered yapya vyadhi (palliative disease). Moola (origin) of mootravahasrotasa is basti (urinary bladder) and vankshana (pelvic region including kidneys, adipose tissue, and the urinary bladder) [8]. Vrukka (kidney and adipose tissue) can co-relate as it is formed from rakta and meda dhatu mainly [9], and it is moolasthana for medovaha srotas.

In CKD, the involvement of multiple srotas notably rasavaha, udakavaha, mootravaha, and medovaha is evident. The disease initially affects dushyas mainly rasa, rakta, mootra, and udaka but later extends to all dhatus (tissues) and upadhatus (secondary tissues). The vitiated kapha dosha obstructs the micro-channels, causing microangiopathy due to its guru (heavy) and picchila (sticky) qualities. Pitta dosha contributes to inflammatory processes and tissue necrosis due to its ushna (hot) nature, while vata is responsible for tissue degeneration and structural deterioration of the kidneys because of its ruksha (dry) and khara (rough) qualities. This collective vitiation of doshas leads to a progressive decline in renal function.

The primary function of the kidneys is to eliminate malas (metabolic waste products), including serum creatinine, blood urea, and other nitrogenous wastes. In CKD, the impaired function of the kidneys results in the retention of these waste products in the blood. This accumulation of mala can be considered malasanchayajanita ama (toxins arising from the accumulation of waste). This process is further aggravated by jatharagni mandya (impaired digestive fire) and dhatvagni mandya (weakened tissue metabolism), which hinder proper digestion and tissue metabolism, causing the buildup of ama (toxins). The combination of kidney dysfunction and impaired metabolic processes leads to the pathological state seen in CKD, where metabolic waste cannot be properly eliminated, worsening the disease progression. These symptoms indicate the systemic impact of the retained malas and the progression of the disease, highlighting its chronic nature. Lakshana samprapti (symptomatology and pathogenesis) is given in Table 4.

Table 4.

Lakshana samprapti.

No.	Laksana (signs and symptoms)	Dosha	Guna	Dushya	Srotasa	Agni
1.	Reduced GFR	Vata	All	Mutra	Mutravaha	Mandagni
2.	Edema	Kapha	Guru	Rasa udaka	Rasavaha udakavaha Mutravaha	Mandagni
3.	General weakness	Vata	Laghu	Rasa	Rasavaha	Mandagni
4.	Loss of appetite	Kapha	Guru, sheeta	Rasa, anna	Annavaha, rasavaha,	Mandagni
5.	Nausea/vomiting	Kapha	Guru	Rasa, anna	Annavaha, rasavaha	Mandagni
6.	Breathlessness	Kapha	Sheeta	Rasa	Pranavaha	Mandagni

Ayurveda treatment of CKD focuses on medicines that act on the mootravaha srotas and have tridosha shamana (balancing of the three doshas) as well as rasayana (rejuvenation) properties. Also, niruha basti (decoction enema) and lekhana dravyas (drugs having scrapping effects) will do malanirharana (elimination of accumulated waste products). These treatments help to pacify the aggravated doshas, regenerate the affected tissues, and improve the function of mootravaha srotas by removing malasanchayarupi ama. As a result, by breaking the pathophysiology, Ayurveda treatment may slow the progression of CKD, improve kidney function, and reduce the need for hemodialysis and transplantation.

Glomeruli are damaged in CKD primarily due to inflammation and the accumulation of toxins. This damage disrupts their essential filtering function, leading to a decline in kidney performance. Initially, the inflammation and toxic exposure can cause hyperfiltration in the remaining healthy glomeruli, as they attempt to compensate for the loss of function. However, as the condition progresses, this compensatory mechanism fails, resulting in a significant reduction in eGFR and the retention of waste products in the bloodstream [10]. Rasayana drugs particularly those, that act on mootravaha srotasa possess the potential to reduce this tissue damage, by enhancing the functional qualities of remaining intact glomeruli that have not yet experienced damage. By improving the resilience and efficiency of these unaffected glomeruli, Rasayana drugs enable them to compensate for the loss of function associated with damaged nephrons. This adaptive mechanism is crucial for sustaining normal physiological functions of the kidney.

Without the intervention of rasayana drugs, healthy nephrons may face an excessive workload due to the loss of their damaged counterparts. This overload can lead to further deterioration of the remaining healthy nephrons, exacerbating kidney dysfunction.

Moreover, prolonged use of rasayana drugs may facilitate the repair and regeneration of damaged renal tissues. Consequently, this not only aids in the recovery of the affected nephrons but also increases the overall resistance of healthy renal tissues to further damage.

Gokshura (Tribulus terrestris) is rasayana of mootravahasrotasa and it has mootrala (diuretic) and shothahara (anti-inflammatory) properties, it is balaprada (increases strength), brimhana (nourishing), and used in Mutrakricchra (difficulty in micturition), Ashmari (kidney stones), Prameha (group of urinary disorders), Vidahanasaka (cures burning micturition) [11]. A study conducted by Pei et al. (2021) highlights that Gokshura protects glomerular endothelial cells in hypertensive renal injury by modulating the mir-155-5p-h2ac6 interaction network. This mechanism reduces oxidative stress, inflammation, and cellular damage in the nephrons [12]. By upregulating mir-155-5p, Gokshura mitigates endothelial injury, enhances nephron functionality, and prevents further deterioration, thus supporting its classical rasayana action on mootravahasrotas. Its bioactive compounds, particularly saponins, play a crucial role in this protective effect, making Gokshura a valuable agent in the prevention and management of CKD.

Gokshuradi guggulu is used for treating disorders of the mootravaha srotas, such as Prameha, Mutrakricchra, Mutraghata (urinary retention), and Ashmari [13]. The primary ingredients of Gokshuradi guggulu have rasayana effects. Guggulu, one of its components, has lekhana properties that help clear blockages in the kidney's microchannels, thereby improving kidney excretory functions. Rasayana churna (Tribulus terrestris, Tinospora cordifolia, Phyllanthus emblica) has rasayana properties [14]. Svadamstra rasayana is formulated from Gokshura churna bhavana (a process of triturating a substance with the same or similar liquid juice or decoction) with Gokshura svarasa (extracted juice) [15], exemplifies the principle of bhavana as described by Acharya Charaka as bhavana with the same drugs repeatedly enhances the potency of the formulation, leading to quicker therapeutic action and potentially reducing the required dose. The repeated bhavana of Gokshura improves its rasayana properties [16].

Kantaphalabhrarasa is an Anubhuta yoga (empirically proven formulation) based on Ayurveda principles, comprising of Abhraka Bhasma (Purified and calcined mica) that destroys Mutraghata, Mutrakrichra, Ashmari, acts as a rasayana, and does agnideepana (kindles digestive fire) [17]. Rasaratnasamucchaya mentions that it destroys vata, pitta, and kshaya, and does shamana of all rogas, it is vrishya (aphrodisiac), ayukaraka (longevity-enhancing), balakaraka (strength-promoting), ruchikaraka (appetite-enhancing), agnideepaka, sheeta veerya (cold potency), snigdha (unctuous) and also enhances pragnya (wisdom) when taken with specific dravya, it acts on the disease related to that particular dravya. For example, when taken with Gokshura, it acts on mootravahasrotasa (urinary system) [18]. That is why Gokshura was specifically chosen. Abhraka bhasma exhibits significant therapeutic potential due to bhavana with Gokshura svarasa. Samyoga refers to the enhancement of the drug's properties, broadening its therapeutic utility. This is backed by scientific study, Abhraka bhasma's biocompatibility is enhanced by Gokshura, facilitating organometallic complex formation that improves absorption and transport in human tissues. This synergy increases bioavailability and reduces toxicity risks from nonabsorbed inorganic metals. The formulation effectively targets the mootravaha srotas, promoting renal function and long-term tissue resilience. It is reported that when bhasma nanoparticles are integrated with biological molecules (in organic liquid media), their stability, functionality, bioavailability, biocompatibility, and bioefficacy are improved [19].

Bhumyamalaki (Phyllanthus niruri) is also rasayana and it has been investigated for its effects on CKD, the study demonstrated that Phyllanthus niruri aqueous extract helps maintain normal kidney function and mitigates histopathological changes by improving markers related to oxidative stress, inflammation, fibrosis, and apoptosis. Specifically, it enhanced antioxidant enzymes like superoxide dismutase, catalase, and glutathione peroxidase, and reduced inflammatory markers such as tnf-α, il-1β, and il-6 [20].

Tab uricare contains Crataeva nurvala, Boerhavia diffusa, Tinospora cordifolia, Shuddha Shilajita, and Shuddha Guggulu, known for their traditional use in mootravahasrotasa [21].

Brahmighrita nasya helps address stress, mental fatigue, and psychosomatic factors that worsen disease progression. Brahmi, a medhya rasayana with neuroprotective and anxiolytic properties, reduces cortisol levels and mental stress [22].

Whereas, blockage can be removed by lekhana drugs having a scraping effect on blocked channels. Varunadi kvath is known for its lekhana karma, thus addressing vitiated kapha and vata doshas [23]. According to Sharangdhara samhita (Purva khanda, chapter 1, verses 37–38), the determination of drug dosage should be flexible and adapted to the Kala (season), Agni (digestive capacity), age, strength, and Prakriti (constitution) of the patient. It also highlights the concept of Kalingamana, describing people of the Kaliyuga as having diminished digestive capacity, physical strength, and mental power. Considering our patient, who was in an advanced stage of CKD and exhibited signs of exhaustion, we adjusted the administration by dividing the total 96 ml daily dose into two 40 ml doses, given morning and evening. This approach ensured better tolerance and compliance while still adhering to therapeutic principles.

8.1. Niruha basti with Punarnavadi kvatha

The main sampraptighataka of CKD is malasanchayarupiama, which is accumulated in the blood, so to break this samprapti, malanirhana must be done that's why we administered Niruha basti daily which helps to remove accumulated malas, and thus restores the normal functions of kidney [24]. By reducing the toxic load and breaking the main sampraptighataka of CKD, Basti chikitsa can potentially delay the need for dialysis and improve overall renal function, as observed in this case. The modification of the Niruha basti dose from the classical 960 ml–320 ml was a clinical decision based on the patient's specific condition and tolerance levels. In advanced CKD G5, with symptoms such as bilateral pedal edema, breathlessness, and general weakness, a full dose could potentially exacerbate these symptoms and pose safety risks. Reduced dosage in such cases is supported by Acharya Charaka (Charaka samhita, siddhi sthana, chapter 8, verses 3, 7, and 12), which recommends madhyama matra (moderate quantity) or chatuprasrutika basti for patients who are sukumara (delicate) or debilitated [25]. This adjustment aimed to balance therapeutic efficacy with patient safety, ensuring the treatment was effective without inducing adverse effects, thereby following classical principles while adapting to the patient's clinical needs. The normal function of the kidney is to excrete metabolic waste from the body, which is hampered in CKD, Niruhabasti helps in malanirharana (removing mala from the whole body). Hence, niruhabasti can be a minor alternative to hemodialysis.

This treatment schedule could break down the samprapti and was helpful in removing the samprapti ghataka which has created the main pathophysiology of the CKD.

9. Conclusion

Ayurvedic treatment effectively benefited the CKD patient, eliminating the need for hemodialysis, improving eGFR and hemoglobin, and stabilizing serum creatinine and blood urea levels. These improvements remained stable for two years despite discontinuing all medications except antihypertensives. While conclusions cannot be drawn from a single case, this case highlights the potential of Ayurvedic management for CKD, warranting further research.

Informed consent

Written permission for the publication of this case study was obtained from the patient.

Patient's perspective

It was recorded on January 19, 2024. “Two years ago, my life took a sudden turn when I started experiencing nausea and vomiting. Little did I know, it was the beginning of a challenging journey with CKD. Despite being relatively healthy before, the symptoms gradually worsened, leading to abdominal pain, breathlessness, and swelling on the face and legs. The severity of the condition became evident when oxygen levels dropped, requiring hospitalization and hemodialysis.

The ordeal continued as I underwent numerous hemodialysis sessions, hoping for relief from the symptoms. However, despite the treatments, creatinine levels remained dangerously high, and the nephrologist suggested kidney transplant surgery, an option I couldn't afford. Desperate for a solution, I turned to P. D. Patel Ayurveda Hospital.

Under their care, I experienced a significant improvement in symptoms and laboratory results. Hemodialysis became less frequent, and eventually, I no longer required it.

As continued with the prescribed oral medications and strict diet regimen, creatinine levels gradually decreased, and overall health improved. Reaching a point where I could discontinue most medications was a testament to the effectiveness of this treatment. Today, I am grateful to have regained quality of life, returning to work without the burden of hemodialysis and enjoying each day to the fullest.”

Author's declarations

The authors certify that they have obtained patient consent. The patient have given his consent for his images and other clinical information to be reported in the journal. The patient understands that their name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Author contributions

All authors contributed to the acquisition of data, analysis, and interpretation of results. Each author reviewed and approved the final version of the manuscript for submission. Additionally, the corresponding author ensured that all aspects of the work were appropriately addressed and that any questions related to the accuracy or integrity of the work were resolved.

Declaration of generative AI in scientific writing

During the preparation of this work, the author (corresponding author) declares that no tools, services, or AI technologies were utilized in the writing process. Only basic tools, such as the Grammarly app for grammar checking, were employed. The author has no other disclosures to make regarding the use of generative AI in this manuscript.

Funding sources

None.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.