6.1 Modern Literature Discussion 1) Diabetes in...

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Modern Literature Discussion

6.1 Modern Literature Discussion

1) Diabetes in CKD:-

Diabetes is the cause for CKD in long term or ongoing treatment patients the

pathogenesis mentioned in literature is as below and as well observed in patients of

CKD.50

Elevated Hyperglycemia

Hyper Filtration

Elevated GFR

Micro Albuminria

Progressive Endothelial Dysfunction

Loss of Glomerular Basement Membrane

Interstitial Fibrosis

Pathway I Pathway II

Glomerular Collapse Tubular Atrophy

Leads to reduction in GFR of Patients Reduction In GFR

Flow Chart No.5: Diabetes in CKD

2) Hypertension:-

The hypertension is observed as vyadhi hetu for CKD all stages.

Hypertension

Renal Vasculopathy Rennin

Pre Glomerular Artery Arterioles Angiotensinine

Wall Thickening Vasoconstriction

Dysfunction Leads To HT.

Mesangial Hypertrophy Oxidative Stress

Surface Area Vasoconstriction

GFR Less Excretion

Flow Chart No. 6: Hypertension

50 J. M. Lopez – Novoaetal / Pharmacology and therapeutics 128 (2010) 61-81., Harrison’s internal

medicine 17th edition II, 1762.

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3) Creatinine Pathway:-

Creatinine excretion is function of muscle mass. Both creatinine and its

energy reserve from phosphocreatinine are present in muscle, brain and blood.

Creatinine (creatinine anhydrase) is formed in muscle form creatinine phosphate by

irreversible non enzymatic dehydration and loss of phosphate. The 24 hours

excretion of creatinine in the urine of the given subject is reasonably constant from

day to day and proportionate to muscle mass. Traces of creatinine also normally

occur in urine.51

Glycine – Arginine, Methionine

Creatinine Biosynthesis

Guanidine Group

Arginine Glycine

Guanidino Acetate

Kidney

Muscle Liver

Methylation of Gunanidino Acetate

Liver Sudenosylmethionine

Muscle

Creatinine Synthesis

Flow Chart No. 7: Creatinine Pathway

51 Harper’s Biochemistry, 25 edition, Robert K. Murray.

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4) Urea Pathway:-

Urea is the major end product of nitrogen catabolism in human, urea

synthesis in the liver released into blood and cleared from kidneys, constituted 80 to

90 % of the nitrogen excreted.52

MS Liver Post Absorptive Phase

Alanine and Glutanine

Muscle Released From

Circulation

Alainine

Transport of Nitrogen

Liver

Glutamine

Gut + Kidney

Conversion of Alanine

Glutamine source for excretion Ammonia from Kidney

Kidney provides serve Liver + Muscles

Valine Muscles

Brain

Flow Chart No.8 : Urea Pathway

52 Harper’s Biochemistry, 25 edition, Robert K. Murray.

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5) Manifestation of attributes of CKD are:53

Modern Ayurveda

1) Cardiovascular system

Cardiomyopathy

1. PranvahaStrotas

Ayasenashawas

Shawaskashta

2) Nervous system

Cramps

Fatigue

Headache

Sleep disorders

2. MamsavahaStrotas

Pindikodweshatana

Klama

Shirshoola

Anidra

3) Hematological system

Bleeding

3. RaktavahaStrotas

Shotha, pale skin

4) Immunological

Stimulation of inflammation

4. Shotha

5) Bone disease

Osteomalacia

5. Bone disease

Sandishoola, kriyakashtata

6) Skin

Purities

Melanosis

6. Rasavaha Strotas

Kandu

Vaivarnya

7) Gastrointestinal

Anorexia

Nausea

Hiccups

Nausea & Vomiting

7. AnavahaStrotas

Anannabhilasha

Hrullas

Hikka

Chhardi

8) Miscellaneous

Thirst

8. Udakavaha

Trishna

Diabetic Nephropathy Pathway Ayurveda Prameha Pathway

Hyper filtration

Elevated GFR

Microabuminimia

Progressive endothelial dysfunction

Loss of glomerular basement membrane

Interstitial fibrosis

Glomerular collapse Tubular atrophy

Hetu Sevana

Kleda dushti

Dushit Mutra nirmiti

Mutrakshaya khavaigunya

Kleda dushti upalepana of vrukka

Karya dushti of meda & rakta dhatu

Mutra Sangraha Mutrabahulya

53 API text book of Medicine, 8 edition, Shahils Clinical Medicine.

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HT

Renal Vasculopathy Renin Angiotensinin

Wall thickening Vaso constrictions

Dysfunction Leads to HT

Mesangial hyper trophy Oxidative stress

Surface area Vasoconstriction

GFR reduction GFR reduction

Hypertension

HT Ayurveda

Agni dushti54

Dosha dushti

Vayna vayu & Rasa dathu – vishepana dushti

Dushit dhatu

Rakta Mamsa Meda

Dhamanya kathinya

Vydhi vyakta

Hypertension of Ayurveda

54 Ch. Chi. 15.

Updhatu sira snayu-sneha

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Vyadhi hetu: -

As symptom and complication is observed.55

Anemia

Insufficient Production of Erythropoietin

Diseased Kidney Cell

Iron deficiency Acute

Due to Inflammation

Impaired Utilization Chronic

Hyperparathyroidism

Fibrosis Bone Marrow

Shorten Red Cell Survival in Uremic Condition

Foliate Deficiency

Tissue Oxygen Delivery

Utilization

Increased Cardiac Output

Increased Cardiac Output Ventricular Dilation Ventricular Hypertrophy

Heart Failure Mental Acuity Prone for Infection

Flow Chart No. 14 : Vyadhi hetu

55 Handbook of Nephrology, J. M. Lopez – Novoaetal / Pharmacology and therapeutics 128 (2010)

61-81.

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Ayurveda Literature Discussion

6.2 Observation:-

Mutra its relation with Santarpan hetu:

In Charak samhita Santarpaniyadhya- Snigdha, Madhur, Guru, Pichhil,

Navanana, Madya, Anup mamsa all these hetus are causative for the Santarpan

vydhi. Basically Santarpanotha vyadhi are those caused due to assimilation of dosha

dushti in Strotas causing Indriyalepana. The diseases caused by the Santarpan hetus

are followed Prameha, Kandu, Pandu, Aamadosha, Jwara, Tandra, Athisthoulya,

Aalasya, Mutrakruchhra and Shotha.

Santarpan Hetus

Madhur, Snigdha, Guru, Pichhil, Navana, Madya

Agni dushti

Dushit Ahara Rasa (Kleda nirmiti)

(Strotas Avarodha, Indriyalepana)

Rakta, Meda dhatu dushti

Vyakta vyadhi

Diseases: Prameha, Kandu, Pandu, Jwara, Mutrakruchtra, Atistholya, Aalasya,

Shotha56

Flow Chart No. 9: Mutra its relation with Santarpan hetu

Mutra Poshana Relation:

The Avidagdha Kapha, Pitta and Vayu are outcome of avasthapaka from the

ahara rasa. The respective Madhur, Amla and Katu vipaka are produced. The vipaka

leads to saara kitta vibhajana of ahara rasa. From this kitta Mala and Mutra are

formed. Mutra is katu rasatamak (Agni and jala dominant).57

56 Ch.Su.23/3-7

57 Su .Su 46/527

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Ahara

Three states of Avastha Paka

Madhur Avidagdha Kapha

Amla Avidagdha Pitta

Katu Vayu

Vipaka – Madhur, Amla, Katu

Saara Kitta Vibhajan

Mala Mutra (Katu Vipaki)

Katu- ( Agni+ Vayu)

Vayu Poshana

Prakrut Rookshadi Sharir Kriya

Prakrut Mutra Formation

Flow Chart No. 10 : Mutra Poshana Relation

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Mutra and Ajeernashan relation:-

The state of ajeernashan is that when previous ahara is not digested well, then

it leads to Ajeerna. The ajeernashan causes vidagdha avastha, leading to tridosha

prakopa. The prakopita doshas are causing avarodha of Strotas leading to diseases.58

The apakva ahara rasa leads to tridosha prakopa causing agnimandya and

Stroto avarodha especially mutravaha Strotas. The dushit kleda leads to

mutrakruchhra. The diet according to state of Agni is important feature of CKD.

Ajeernashan

Vidgadha Avastha

Agnimandya

Tridosha Prakopa

Strotas Avarodha (Mutravaha Strotas)

Dushit Kleda Formation

Vrukka

Mutrakruchhra

Flow Chart No. 11 : Mutra and Ajeernashan relation

Vyana vayu, Agni Relation:-

The rasa, rakta and remaining dhatus are circulated in body continuously with

Vyana vayu. The disturbance in this normal continuous functioning of vyana vayu

leads to Strotas vaigunya. The disturbed doshas leads to sthanashanshraya in vrukka

as per hetus into an established vyadhi.59

58 Ch. Chi 15/42-44 59 Ch. Chi. 15/36-37

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Hetu

Dosha prakopa

Rasa rakta dhatu dushit

Sthana – Vrukka as sthana vaigunya

Vrukka vikara

Flow Chart No. 12 : Vyana vayu, Agni Relation

Apatarpan hetu Relation:-

The hetu Katu, Kakshaya, Tikta and Paryusheet ahara sevana observed. The

aatap, jagaran, vyayama, krodha, shoka are apatarpan hetu.60

Apatarpan hetus

Ahara - Katu, Kakshaya, Tikta

Vihara - Aatap, Jagaran

Manasa - Krodha, Shoka

Guna - Rooksha, Ushna

Rasa Mahabhuta – Agni + Vayu

Sthana Grahani -

Agni Dushti

Disturbed Functions

Vata Dosha

Rakta Dushti

Mutrasangrha

Karnadushti (lakashana of end stage)

Flow Chart No. 13: Apatarpan hetu Relation

60 Ch. Su. 23/26-28, page 123.

Vyana Vayu

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Antardaha and shitakamitva-

The Shaitkamitva and Antardaha are lakshanas observed. These lakshanas are

observed in samhita as meda kshaya, rakta and pitta dosha dushti.61

The patient

expects for ushna ahara and vihara.

Manasahetu in CKD:-

The shoka and krodha are manasa hetus observed in patients. The effect of

these hetus leads to rasavaha, medavaha & swedavaha strotas dushti in CKD.62

Pandu:-

The Pandu can be apparently a hetu for CKD and dominantly complication of

kidney disease. The Santarpan, Aptarpan and Viruddha are basic hetu for CKD also

these hetus attributes for Pandu.63

In this process because of hetus dosha dushti is vata, leading to rasa dushti

along with Agni. Thus in turn disturbs rakta and meda dhatu. Consequently rakta

mala – Pitta & sneha of the meda dhatu are disturbed/ hampered. These again

contribute to vata dushti as well as present them in the dushit form as Pandu.

61 Va. Su. 11/16 62 Ch. Chi. 15/239 63 Ch. Su. 23/123

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Apatarpana /Ajeerna samprapti

Viruddha / Diwaswap / Krodha / Shoka/ Vishamashana

Vata dosha dushti

Rasa dhatu dushti

Rakta, Meda dushti (sneha )

Sthanashanshraya

Vrukka

Lakshana observed

Karnashweda Pindikodweshatana Akshikutashopha

Flow Chart No. 15 : Pandu

Prameha:-

In CKD Prameha is observed as a vyadhi hetu for many cases. In the

Prameha vyadhi both Apatarpana and Santarpana hetus are observed in samprapti of

Prameha.

Prameha in CKD:

1. Santarpana

2. Apatarpana

Santarpana:

The santarpana hetu sevana Diwaswap, Abhishyandi, Guru Ahara etc leads to

kapha dushti. Mainly shleshamika guna is aggravated disturbing further meda dhatu;

both contribute for dushit kleda vruddhi. This kleda vruddhi in turns results in

mutrabahulya.64

64 Ch. Ni.4/8

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Apatarpana:

The Apartapana hetu such as Rooksha, Katu ahara, Jagarana, Aatapa etc.

leads to vata dosha dushti which creats shosha to itself and dhatus particulary rasa

and meda. In turn disturbs kleda. That means sneha guna is hampered. Eventually

leads to vrukka dushti and mutra dushti.65

Hetu sevna

Guru Ahara, Asyasukha, Diwaswap Rookshahara, Jagaran, aatap

Santarpana Hetu Apartarpana

Kapha Meda Dushti Vata Dosha Dushti

Kleda Vruddhi Shosha

Kapha meda & kleda dushti Vata, Meda & Kleda

Mutrabahulya Mutra Pravartana dushti

Vrukka Dushti

Mutradhikya / Alpatava / Mutra dushti

Flow Chart No. 16: Prameha

Prameha as vyadhi hetu, Prameha samprapti (kleda dushti) leads to changes

in karya (function) and sharir (structure) of vrukka. This leads to deranged function

of excretion.66

HT Vyadhi Hetu:-

Basically HT is observed in patient as a cause for CKD. The HT Anukta

Vyadhi can be treated as vata dominance vyana vayu & pranadushti leading to

alteration in samvahana. The hetus are manasa, aharia, viharia and viruddha causes

were observed.

65 Ch. Ni. 4/9 66 Ch. Ni. 4/3-4, page 212.

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HT

Hetu sevana

Vata vruddhi

Vyana and pranadushti

Sthanashanshraya

Vrukka

Flow Chart No. 17 : HT Vyadhi Hetu

Proteinuria:-

The proteinuria is detected in stage 1 to 3 mainly. This means kaphadosha

causes meda dushti leads to vrukka dushti through kleda. Here medaposhakansh

from vrukka gives rise to mutra dushti.

Kapha doshadi

Meda Dushti

Kleda Dushti

Vrukka

Meda poshakavansha

Mutra Dushti

Flow Chart No. 18: Proteinuria

Protein

Micro protein sthula and sushama

24hr protein loss of protein can be observed

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As mutra is katu rasa, pradhana. It clears the rasa and rakta dhatu by

removing rasa, rakta mala from circulation and excretion through kidneys. Hetu

sevana leads to disturbance of normal functioning of Kleda giving rise to Proteinuria/

Mutradushti.

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Clinical observation discussion

6.3 Clinical observation discussion:

The trishna lakashana observed as Prakrut lakashana in 50.9% and the

Aprakrut trishna observed in 49% patients.

The uvula normal in 48.3%, the elongated uvula in 48.2% & others 8.2%

patient’s are observed. Thus the elongated uvula shows Mamsavaha Strotas dushti

and Medovaha Strotas dushti.

The Sama and Nirama Jivaha observed in patients .The Niram jivaha

observed in 14.5% patients, indicating normal pachana. The Sama jivaha is observed

in 85.5% patients. Thus the Sama jivaha indicates pachana is disturbed.

The Agni pariksahna in patients of CKD is as follows the Sama Agni 43.6%,

vishama Agni 15.5%, tikshana Agni 10.0% & manda Agni 30.9% are observed. The

manda Agni actually is the main cause for disease.67

The Abhyavaran Shakti of patients of CKD is observed .The prakrut

abhyavaran 74.5% and the aprakrut abhyavaran 25.5% is observed. Thus pachana is

disturbed in such patients.68

The normal skin 18.7%, dry skin 47.3%, scaly 15.3%, scratch mark 12.0% &

pale skin 21.3% are observed. The twak is vata sthana (sparshnendriya) and its dushti

lakshanas are observed in patients. The twak is updhatu of mamsa dhatu; which

signifies twak dushti suggestive of mamsa dushti in CKD patients.69

The percentage of eyes pallor is 73.4%.The non pallor eyes in 26.4%.The

pale eyes are suggestive of rakta dhatu dushti in CKD.

The muscle fatigue absent in 33.6% & present in 66.4% is observed.

The renal angle tenderness is observed in 10% patients and the non

tenderness observed in 90% patients.

67 As. Sa. Su 68 Ch. Chi. 15/18-19 69 Ch. Chi. 15/18-19

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The percentage of pale, clubbing, koilonychias and normal conditions of nails

observed. The pale nails observed in 82.7% patients. Clubbing 10.9% & the

koilonychias 2.7% are observed.

The hair fall observed in 48.2% patients .The hair greying observed in 57.2%

patients. Hair fall observed as swedvaha stroto dusti lakshana in patients 48.2%. The

hair greying is observed as Pitta & Rasa dushti lakshana.70

The daily mala pavarthana 94.5%, mala a pavarthana 4.5 %, formed mala

75.5%, kruchhratava 28.2% is observed. The bowel habit in present data is non

significant due to sweda & mutradushti mainly. Hence it indicates mutra & sweda

dominantly hampered but invariably purisha is mostly normal in CKD.

The sweda pravartana observed in summer 68.2% ,sweda absent in 31.8%

while sweda absent in all season 91.8% and sweda present in all 8.2% patients. The

sweda nourishes twak & roma. The disturbances in sweda pravartana are suggestive

of kleda dushti. The swedapravartana absent in 31.5% this shows that twakgat sneha

is dusht. This indicates dushit kleda directly disturbed twak sneha representing

lakshanas dry skin & itching.71

The normal auscultation observed is 68.2 % and the abnormal auscultation

36.81%. Here Pranavaha Strotas dushti is observed.

The distribution of percentage observed in patients of DNS- 12.7%, dryness

69.1%and polyp 18.2%. The nasal dryness and polyp is the cause for dushti of kapha

& vata dosha.

The lips normal, dry and scaly are observed in patients .The percentage of

normal lips patient is 23.6% .The dry 46.4% and scaly 30.0 %.

70 Va. Su. 11/22 71 Va. Su. 11/5

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The soft palate normal 62.7% patient and dry palate 37.3% patients observed.

The talu kloma are the mula sthana of Udakavaha Strotas. Hence, dushti of

udakavaha strotas were observed.

The normal salivation 40.9%, less salivation patients 56.4% and excess

salivation 2.7 % were observed.

The pigmentation absent in 66.4% and the pigmentation present in 33.6% are

observed. However, Raktavaha Strotas dushti lakshana were observed here.72

The sandhi kriyakashtata observed in 24.5%. The sandhi is the basic site for

majja dhatu. The majja is having medaposhakansha in it. The correlation of majja

dhatu in CKD is observed as the (sarakta sneha) majja dhatu dushti is observed with

disease progression from stage 1 to stage 5.73

The numbers of patients undergoing dialysis were observed 66.45% and the

33.6%non dialysis observed .The dialysis is conventional treatment for end stage.

The daytime frequency of urine 1 to 4 times 45.5%, 4 to 8 times 51.8%, 8 to

12 times 2.7%. The urine frequency at night 1 to 4 times 20.9%, 4 to 8 times 69.1%

& 8 to 12 times 10.0% are observed. The urine burning and pain in lower abdomen

patients observed were 18.2%.

The hypertension absent in 32.7% and hypertension present in 67.3%

patients.

63.6% were Diabetic where as 36.4% were non DM.

The numbers of patients observed HT+DM were 24.5% .The vydhi hetu as

DM+HT were observed.

The staging observed were stage 1st - 13.6%, stage 2nd - 9.1%, stage 3rd -

16.4%, stage 4th - 28.2% and stage 5th 32.7%.

72 Ch. Su. 28/12 73 Ch. Vi. 5/8

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The diseases observed were Asthma, HT, DM, Kidney disease and polycystic

disease of kidney.

The DM – 12, HT- 8, Kidney Disease -4, IHD -2, Asthma -3, and Cancer-1

observed. The percentage of DM & HT disease were mainly seen.

The kidney disease 6, DM -2, HT- 1, IHD -1 patient observed. The hereditary

cause is dominant in swakul history. It shows that bijadushti is main reason for

disease occurrence.

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Observational Discussion

6.4 Observational Discussion:-

Stage 1 and Ahara Rasa

The combination of Amla, Lavana sevana patients were observed. It

suggests that for mild change in filtration, Pitta Vrudhikara rasa are

responsible.The Amla and Lavana are responsible for rakta, mamsa dhatu

dushti. The mamsa dhatu vidaha & shaithilya observed.74

Stage 2 and Ahara rasa

In the stage 2 Katu, Amla and Lavana rasa sevana is observed.75

The

Katu, Amla and Lavana group of rasa is mainly responsible for Pittaprakopa.

The Prakopita Pitta disturbs Rakta dhatu. Thus Anemia is observed with mild

to moderate grade in CKD.


The dominance of Katu, Madhur and Lavana rasa is observed. This

shows Kapha prakopa along with pitta dushti. This leads to mild reduction in

GFR compare to stage 2. In this stage the status of rakta dushti is observed by

changes in RDW (Red cell distribution width), haematocrit.


In this stage Lavan, Amla and Madhur rasa are significant. This

signifies that pitta prakopa observed along with Kapha prakopa. These doshas

reduces GFR to larger extent and this leads to disturbance in Agni dushti &

saara kitta vibhajana. The disturbed saara kitta vibhajana leading to

accumulation of kitta in Strotas and Panduta, Daurbalya lakashana are

observed.


In stage 5th Katu, Lavana and Amla rasa are observed. The group of

rasa is mainly for Pitta prakopa and kapha dushti. The CKD stage 5 shows

74 Ch. Su. 26/43-44, page 143-45 75 A. Ha. Su. 10/ 12-13, page 175-176.

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deterioration of dhatu mala formation and its excretion, leading rasa mala

kapha and rakta mala pitta dushti. This signifies the dhatu paka avastha.

The creatinine, urea levels are disturbed along with RDW,

haematocrit and moderate to severe Anemia can be observed.

Other than Rasa group of Ahara rasa:-

Stage 1:-

The Mamsahara, Abhishyandi, Paryusheet ahara sevana is not

significant.

Stage 2:-

The stage 2 in which the Mamsahara, Abhishyandi and Paryusheet

leads to dosha dushti. This Guru, Vidahi, Sandra, Vishtambhi ahara disturbs

the pachana leading to udajarjadata, udaradhamana. The vata and kapha

dushti may leads to reduction in GFR.

Stage 3:-

The stage 3 Abhishyandi ahara sevana patients are observed. This

leads to kleda dushti, derangment in dhatuposhana. The Panduta, Shotha,

Anannabhilasha is observed. The GFR is reduced, Anemia, proteinuria or

Albuminuria observed. The Abhishyandi and vidahi ahara is dushti hetu for

Rasavaha, Raktavaha and Mamsavaha strotas dushti leading to CKD

lakshanas.76

Stage 4:-

The dominance of Abhishyandi and Mamsaahara suggests Kapha

dosha dushti with Pitta dushti leading to changes reduced GFR. This is the

cause for Rakta and Mamsavaha Strotas dushti. The Pindikodweshtana &

Panduta is observed.77

76 Ch. Vi. 5/8 page 250

77 Ch. Vi. 5/14-16

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Stage 5:-

The mamsahara sevana patients observed. The associated ahara rasa

group is Abhishyandi & Paryusheet. This leads to Kapha and Vata dosha

dushti leading to Rasa, Mamsa and Medovaha Strotas dushti. The effect of

this ahara is reduction in GFR causing stage 5 as well the moderate to severe

Anemia.

Viharia hetu:-

Stage 1:-

In stage 1 Asyasukha, Vishamashana followed by Aatapa and

Vegavrodha observed. These hetu leads to vata dosha dushti. This leads to

changes in (circulation) samvahana of ahara rasa leading to Vata dushti. This

preliminary stage shows mild level changes in GFR. The dushit dosha

circulation with rasa dhatu – Meda, Rakta contribute to dushit kleda in to

vrukka resulting in CKD.

Stage 2:-

In stage 2 viharia hetu is not significant for vitiation of dosha and

dhatu.

Stage 3:-

In stage 3 Asyasukha and Nidra are mainly observed. These hetus are

causing Kapha dosha dushti & Medovaha strotas dushti. The dushit Kapha

and dushit kleda leads to disturbances in GFR.

Stage 4:-

In stage 4 Diwaswap is significantly observed.78

The Diwaswap is

mainly disturbs kapha dosha leading to kleda dushti directly. The Diwaswap

is the dushti hetu of mamsavaha strotas. The mamsavaha Strotas dushti is

observed in stage 4. The creatinine level is raised. The correlation between

mamsavaha Strotas dushti and its dushti lakashana are observed.

78 A. Ha. Su. 7/53, page 141

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Stage 5:-

In stage 5 the Aatapa sevana is observed as Viharia hetu. The Pitta

and Vata dushti is responsible for disturbance in pachana and saara kitta

vibhajana. This reduces the GFR.

Stages and Manasa hetu:-

Stage 4 and 5:-

The krodha is significantly observed in patients. The krodha is dushti

hetu for swedavaha strotas. The swedvaha strotas dushti lakshana are twak

dryness, scracthmark, sweda absent, kandu were observed. Due to krodha

sadhak pitta dushti occurs which reaches buddhi and causes functional

disturbances of vrukka leading to mutra dushti. The reduction of GFR in

stage 4 is suggestive of Swedavaha Strotas dushti and Pitta dushti. This 4 and

5 stage Pitta dushti is mainly observed.79

Viruddha hetu:-

Stage 1:-

In stage 1 Kala, Virya, Krama and Hrud are significant while Agni,

Matra and Vidhi Viruddha are associated hetus.

Stage 2:-

In the stage 2 – Krama, Hrud, Kala, Agni, Dosha, Virya and Satmya

viruddha are present.

Stage 3:-

In stage 3 Dosha, Virya are significant and associated Koshtha and

Krama are observed.

Stage 4:-

In the Kala, Agni, Matra, Satmya, Virya are significant and associated

Avastha and Krama viruddha are observed.

79 Ch. Vi. & Ch. Chi. 15/18

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Stage 5:-

In the stage 5 Kala, Agni, Matra, Satmya vidhi are significant and

associated Koshtha avastha are observed. The viruddha hetu leads to tridosha

prakopa and directly vyadhi avastha. Finally, functional changes of Rasa and

Rakta dhatu occur.

The viruddha Ahara basically disturbs the functions of dhatus

progressively. This leads to dhatu paka avastha.

The viruddha Ahara is cause for majjavaha strotas dushti, in CKD

majjavaha strotas dushti lakshanas are not observed significantly but murcha

& bhrama lakshanas seen in previous history.

The viruddhahara types are as follows Desh, Kala, Agni, Matra,

Satmya, Doshadi, Sanskara, Virya, Koshtha, Avastha, Krama, Parihara,

Upachara, Paka, Sanyoga, Hrud and Vidhi.80

Stages and Vyadhi hetu:-

Stage 1:-

In stage 1st HT is dominant cause as a vyadhi hetu.

Stage 2:-

The vyadhi hetu DM and HT is observed in stage 2. The DM & HT

vyadhi hetu leads to tridosha dushti and changes in kidney functions.

Stage 3:-

In stage 3 associated vyadhi hetus are significantly observed as HT

and DM. The HT is vyadhi hetu in which vata dosha & rasa dhatu dushti

along with kleda dushti is observed. This kleda may leads to GFR reduction

and excretion of poshakansha from mutra. This leads to irreversible changes

in vrukka.

80 Su. Su. 20/18

Page | 122


Stage 4:-

In stage 4, HT and DM are the main cause for CKD and associated

Anemia is observed. The DM and HT leads to dosha dushti which already

exists in Strotas.

Stage 5:-

In the stage 5, HT and Anemia are significantly observed. The

dominance of vata, pittadosha along with rakta dhatu dushti is observed. The

rakta dhatu dushti with pitta dushti is observed.

Stage and Pradhan Lakshana:-

The Anannabhilasha, Chhardi, Daurbalya, shopha, pranadushti

lakashanas are observed as pradhan lakashanas in CKD.

Stage 1:-

In stage 1, Pradhan lakshana is not significantly observed. The

associated lakshana in stage 1 Daurbalya, Anannabhilasha and Pranadushti

are observed. It suggests that the stage first is having Annavaha, Pranvaha &

Swedavaha Strotas dushti. The pitta dosha is vitiated leading to agni dushti

and pachana.

Ahara - Katu, Lavana, Amla, Paryusheet

Viharia - Nidra

Manasa - Shoka

Viruddha - Kala, Virya, Hrud, Krama

Vyadhi - HT

Stage 2:-

Ahara rasa - Katu, Madhur, Amla

Viharia - Nidra

Manasa - Krodha, Shoka, Nidra, Asyasukha, Diwaswap

Page | 123


Viruddha - Doshadi, Virya, Koshtha, Krama

The associated lakshanas observed are Anannabhilasha, Chhardi and

Shotas. The hetu are responsible for kapha & pitta dushti mainly. These

lakashanas are mainly of Annavaha Strotas dushti laksahana. In stage 2 hetus

of Medavaha, Swedavaha Strotas dushti are observed leading to disturbed

kidney functions.

Stage 3:-

Ahara – Katu, Amla, Lavan, Mamsa ahara

Viharia - Nidra, Asyasukha, Vishmashana

Manasa - Krodha

Viruddha - Kala, Agni, Doshadi, Virya, Krama, Hrud

Vyadhi - HT, DM

The pradhana lakshanas are not significantly observed but associated

lakshana are Anannabhilasha, Chhardi, Shotha, Pranadushti observed. The

Pranavaha, Sweda, Annavaha Strotas dushti lakashana are observed. The

above hetu in stage 3 leads to kapha, Pitta dosha dushti this dushit doshas

along with dominance of Rakta, Mamsa & Meda dhatu shows the above

lakshanas.

Stage 4:-

Lakashanas – Daurbalya, Pranadushti, Anannabhilasha

Ahara – Amla, Lavana, Mamsaahara, Abhishyandi

Viharia – Diwaswap, Nidra, Vishmashana

Viruddha - Kala, Agni, Matra, Satmya, Virya

Vyadhi hetu – DM

In stage 4, lakashana observed Anannabhilasha Daurbalya,

Prandushti. The hetus leads to tridosha dushti along with Rasa Rakta, Mamsa,

Meda dhatu dushti, these dushit dosha & dushit dhatus along with already

Page | 124


present khavaiguya in mutravaha strotas expressed in the form of above

lakshanas.

Stage 5:-

Lakashana – Daurbalya, Pranadushti, Anannabhilasha

Rasa – Lavan, Katu, Mamsahara, Abhishyandi

Viharia – Aatapa, Vishmashana

Manasa – Krodha

Viruddha – Kala, Agni, Matra, Satmya, Virya, Hrud, Vidhi,

Koshtha, Avastha.

Vyadhi hetu – HT, Anemia

The hetu sevana leads to tridosha dushti along with dhatu paka

avastha of basic dhatus in vrukka vikara, Rakta, Mamsa & Meda.81

Rakta – Pitta – Panduta

Mamsa – Vata – Kathinya (Dhamni)

Meda – Kleda – Mutra dushti

81 Su. Su. 20/26

Page | 125

Investigation Discussion

6.5 Investigation Discussion:

1. Hb distribution:-

The Hb % grouped under the criteria of mild, moderate and severe

Anemia. The patients observed in mild Anemia are 38, moderate Anemia –

51 and severe Anemia - 11. In CKD Anemia is observed as lakashana in

previous history and complication. The Rasa & Rakta dhatu dushti is mainly

observed.

2. Blood urea distribution:-

The urea below 50 is 13, between 50 to 100 - 28, 100 to 150 - 14 and

above 150-6 patients observed. The disturbed Saara kitta vibhajana is

significantly observed in end stages.

The urea is the outcome saara kitta vibhajana in initial pachana. It is

nitrogenous waste product i.e. mala is to be expelled out at mutrashaya level.

In CKD mentioned hetus leads to dosha dushti basically Pitta dominance,

Kapha and Vata. Also Rakta, Meda & Mamsa dhatus both uniformly disturbs

the kidney tissues i.e. the vrukka dushti.

3. Serum creatinine distribution:-

The normal value of serum creatinine is 1.2(units) above the normal

value that is considered pathological in the study below 1.6 – 20, between 1.6

to 5- 40 were observed, 5 to 10- 29 and above 10 – 13 patients were

observed.

The creatinine is liberated from muscle mass. The level of creatinine

is important in major GFR in CKD cases. Thus nephron level filtration

hampered may be because of DM, HT & anemia origin which may differ but

the severity of damage of nephron is measured with creatinine only.

Page | 126

Investigation Discussion

4. Pus cells:-

The pus cells 1 to 4 - 18 observed, 4 to 8 – 19 observed & 8 to 12 – 6

patients are observed.

5. Urine protein distribution:-

Trace urine protein present in 7 patients, 1+ urine protein present in 7,

the 2+ in 21, 3+ in 17, 4+ in 8, 5+ in 1 & 6+ in 2 patients observed.

Page | 127

Samprapti Discussion

6.6 Samprapti discussion:-

The correlation of hetus to dosha ,dhatu and sthana observed .Thus

,shatkriyakal samprapti of CKD is mentioned in correlation with different

precipitating factor from ahara,vihara ,manas,viruddha and vyadhi hetu.

To establish samprapti of CKD with Ayurveda perspective the hetus are

observed in correlation with clinical observation and investigations. The hetus are

classified & categorized in Apatarpan, Santarpan, Vyadhi hetu & Manasa hetu. The

Apartapan hetu are those responsible for Apatarpan and Vata vruddhi as well

Santarpan are the hetus responsible for kapha vruddhi & kleda dushti.82

Santarpan samprapti:-

Aharia - Madhur, Amla, Lavan

Viharia - Asyasukha, Diwaswap, nidra.

Manasa -

Viruddha - Agni, Satmya, Doshadi, Parihara

Vyadhi - DM

The hetus are dominant in Kapha prakopa & kleda dushti. Viruddha hetus are

responsible for dosha prakopa directly. This prakupita dosha dushti in rasa is

circulated as savahana throughout sharir through vyana vayu. This vyana vayu and

rasa dhatu circulated with dushit dosha & dhatu causes khavaigunya in mutravaha

strotas leading to sthanashavashraya in vrukka. The progression of CKD depends

upon dushit dosha & involvement of dushit dhatu.

Thus sthanavaigunya in vrukka and then lakshanas are observed as

Daurbalya, Anannabhilasha, Shopha, Hrullas, Chhardi & Pranadushti.83

82 Ch. Su. 26/3 83 Ch. Chi. 15/16

Page | 128


Hetu Sevana

Kaphadi Dosha Prakopa Prakopa

Kleda Vruddhi

Vyana vayu Rasa dhatu Prasaara

Mutravaha Strotas

Vrukka Sthanashanshraya

Vyadhi Vyktavastha Vykta Avastha

Anannabhilasha, Chhardi, Shoth, Prandushti, Daurbalya Lakshana

Hikka, Urashool Bheda

Flow Chart No. 19: Santarpan Samprapti

.

Apatarpan hetus and samprapti:-

The Apatarpan hetu leads to Vata prakopa and dhatu dushti (shoshana) above

hetus are responsible for vitiation of vata dosha and Agni dushti along with dhatu

dushti. The dushit dosha and dhatus are circulated with vyana vayu and rasa dhatu

throughout sharir. The sthanashanshraya observed in Pakavashya & vrukka. Then

vyadhi vyakta avastha is occurs. (Refer to flow chart no. 15)

The number of patients observed is DM, HT and Anemia as vyadhi hetu.

Page | 129


Vyadhi hetu and samprapti vichar:-

The vyadhi hetus are responsible for tridosha dushti & Rakta, Meda &

Mamsa dushti. The dushit dosha along with dhatu dushti circulated in sharir with

vyana vayu and rasa dhatu settled in vrukka. The vrukka shows vykta avastha of

Vyadhi showing lakshanas Daurbalya, Anannabhilasha, Shopha, Hrullas,

Pindikodweshatana.

Hetu

Tridosha

Prakopa

Rakta Meda Dhatu

Vyana Vayu + Rasadhatu Prasaara


Lakshanas of CKD Vykta Avastha

Urashool, Murchha Bheda

Flow Chart No. 20 : Vyadhi hetu and samprapti

Aushadha Sevana Samprapti:-

The hetu as aushadha sevana mainly analgesics were used. Since most of the

patients were on modern analysis medicines, they were predominately from tikta rasa

origin leading to Vata prakopa i.e. vyana dushti causing rasa, rakta & meda dhatus

dushti across sharir.

The prasara avastha of dushit dosha with dushit dhatu throughout the body

and sthanashanshraya occurs in vrukka and yakrut.

Page | 130


Hetu

Aushadhi Sevana

Vata, Pitta Prakopa Prakopa

Rasa, Rakta, Meda Dhatu

Saarava Sharir Prasaara

Vrukka /Yakrut Sthanashanshraya

Lakashanas in CKD Vykta Avastha

Anannabhilasha, Mutra Daha, Shopha, Daurbalya, Kriyakashata

Pandu Bheda

Flow Chart No. 21 : Aushadhi sevana Samprapti

Amshamsha samprapti:-

This is an attempt to mention about samprapti of CKD with vishesha. The

causes are aharia, viharia & manasa as well polycystic kidney diseases.

The prakupita dosha with dhatu circulated through rasa and vyana vayu, the

meda & rakta dhatu dushti are observed. The prakupit dosha & dhatu circulated

through rasa with vyana vayu throughout sharir leading to kha-vaigunya mutravaha

strotas. The vyakta avastha of dosha dushti is observed as pardhan lakshana of CKD.

The polycystic kidney disease is observed as bijadushti disease. In which

indriyadusti is at sharir level, those having hereditary feature has history of

polycystic kidney diseases.

Page | 131


Hetu sevana

Vata / Kapha Dosha Prakopa

Rasa, Rakta, Meda Prasaara

Rasa and Vyana vayu


CKD lakshana observed. Vykta avastha

Flow Chart No. 22: Aanshata samprapti vichar

The lakshana observed as mutradushti observed.

Dosha and Rasa Dominant observed in CKD:-

Vata Pitta Kapha

Stage 1 +

KT

+++

KAL

+

MT

Stage 2 +

K

+++

KAL

+

M

Stage 3 ++

K

+

K

++

ML

Stage 4 --- ++

LAM

++

ML

Stage 5 --- +++

KLA

++

K = Katu A = Amla

T = Tikta M = Madhur

L = Lavana + = Pravara

- = Avara.

Hereditary Bijadushti

Page | 132

Statistical Discussion

6.7 Aharia Hetu:-

The cross table for Amla rasa and Madhur rasa is non significant with

staging. The staging is assessed with GFR, for that aharia hetu are not observed

significantly. The Madhur and Lavana rasa are responsible for kleda vruddhi, as well

as upalepana. The Amlarasa is causative factor for mamsadaha & shaithilya.84

The dosha dominance form stage 1 to 5 is kapha, the lakshanas were

observed mainly Anannabhilasha, Chhardi, Shopha, Pranadushti Lakshana and

Daurbalya. The Amla & Madhur are kapha prakopa and vata shamak (pacifier).

The shaethilya is seen in mamsa dhatu agni dushti leading to disturbances in

creatinine level.

Shoka:-

The shoka is manasabhava. It is feature of meda, shaya, vata vruddhi and

kleda dushti. This leads to disturbing pachana, shoshana karya of pitta as well of

Agni parinamana. Thus shoka and staging is significantly observed. The Shoka

observed as swedavaha and twak dushti lakshana.

Koshtha Viruddha stage:-

The koshtha viruddha is significantly P<0.05 observed. The Koshtha

viruddha ahara sevana leads to disturbed Saara kitta vibhajana. This gives

accumulation kitta and causing disturbances in excretion.

Agni Viruddha and Stage:-

The patients observed Agni viruddha were P< 0.01 significantly. It means the

ahara is not taken as per Agni status. The patients were observed with Manda,

Tikshna and Vishama Agnis. The diet taken by them were of atimatra, singdha,

katurasa sevana. The ahara in accordance with Agni gives proper digestion

(pachana). In each stage Agni viruddha is observed which denotes that Agni

viruddha ahara sevana leads to dosha

84 Ch. Su. 26/ 2- Page 329

Page | 133


dushti leading to improper digestion (pachana). The agni viruddha as per the staging

is Stage 1 –60%, Stage 2 – 100%, Stage 3 -50%, Stage 4 – 87%, & Stage 5 – 72.2%.

Thus improper digestion at the end part of organ means filtration level is deranged.

This is labeled as pachana dushti at vrukka level by viruddha hetus.85

Matra Viruddha & stage:-

The Matra viruddha and staging P< 0.01 were significantly observed. The

Matra (Rashi) is mentioned for individual as per individual Agni. Those who were

not following the Matra towards Agni are causes vata vitiation along with pitta

dushti in them. These vitiation leads to reduction in Saara & kitta vibhjana. This can

reduce filtration and staging.

Paka Viruddha and Staging:-

If properties and procedure mentioned as per texts are not followed or altered.

It disturbs pachana with Agni dushti.

Vidhi Viruddha & stages:-

It is P < 0.00 significant. The vidhi viruddha is the procedure to follow while

having food. It facilitates digestion. The ahara vidhi gives bala, Varna and good

health. The vidhi viruddha hetu signifies that absorptive & post absorptive phase of

ahara sevana and dispersion of ahara rasa improper formation of (dosha, dhusya and

mala) from pachana, leading to disease.86

Asyasukha & stage:-

It is significant P < 0.04. It leads to kapha dushti further leading to kleda

vruddhi or dushit kleda into mutra dushti.

85 Sa. Su – 20/22 86 Ch. Su. 28/4, Ch. Chi. 5/15

Page | 134


DM & staging:-

The DM is the disease of kapha & kleda dushti leading to progression of

disease (P< 0.039).

HT& staging:-

HT is cause for CKD from the vyadhi hetu in each stage HT is observed to be

present in each stage of CKD (P < 0.03).

Anemia & staging:-

The Anemia in the CKD apparently cause and complication. In anemia pitta

dushti along with rakta & meda dhatu is observed.The anemia is observed

significantly. Anemia is present in CKD (P < 0.00)

Daurbalya and Anannabhilasha:-

The Anannabhilasha is Strotas dushti lakshana for Annavaha Strotas and

Daurbalya lakshana are observed in stage 1 to 5 significantly. The Daurbalya present

and Anannabhilasha absent in staging were observed (P < 0.03).

Diwaswap & cortico medullar differentiation:-

The Diwaswap absent is significant P< 0.04 for cortico medullar

differentiation deranged this leads to Varna formation in vrukka leading to structural

changes. The Diwaswap leads to kapha dosha dushti and kleda dushti.

Abhishyandi & Mutra day frequency:-

The abhishyandi ahara sevana is significant P< 0.04 to mutra frequency. The

abhishyandi ahara sevana leads to kleda dushti leading to disturbed mutra frequency.

Page | 135


Multivariant Correlation:-

Agni Viruddha, Virya Viruddha & stage:-

It is significant in staging P < 0.01. The Agni & virya in combination worked

together, it will affect the pachana and the formation of dosha. Agni viruddha

observed leading to ajeerna etc. In the above mentioned group vriya viruddha absent

and Agni viruddha were present.

Agni Viruddha, Paka Viruddha & staging:-

The Agni viruddha creates tridosha dushti dhatu dushti. It is significantly

observed in 5th stage. This tridosha dushti leads to reduction in GFR significantly

(P < 0.01).

Hetu, lakshana & staging:-

The correlation of hetu to lakashana and staging assessment between Aatapa

sevana and patient suffering from Anannabhilasha are non significant. It shows that

viharia hetu i.e. Aatapa is not hetu for Anannabhilasha in CKD. The Anannabhilasha

present and Aatapa hetu absent is observed in staging of CKD. As Anannabhilasha is

actually an Agni dushti lakshana due to samana vayu & disturbed pachak pitta.

Previous History of DM, Anannabhilasha & Shotha:-

The previous history of Diabetics to Anannabhilasha and Shotha is significant

(P < 0.05).

Page | 136


Anemia, Daurbalya & Shotha:-

The Shotha absent and Daurbalya present were (P < 0.03) observed in

staging. While Shotha and Daurbalya in Anemia were reaches to significance (P <

0.08).

Previous history of HT, Daurbalya & Pranadushti:-

In staging Daurbalya absent and Pranadushti present is (P < 0.01) observed.

The dosha dushti leads to Pranvaha Strotas dushti showing Aysenashawasa,

shawaskashta.

Anemia, Lavan & Amla:-

The Amla and Lavana rasa are responsible for pitta & rakta dhatu dushti. It

affects the GFR directly with other hetus (P < 0.05).

Amla, Lavan & Twakdry:-

Twak dryness is observed in patients. The Amla Lavana rasa causes rasa,

rakta dushti and pitta dosha dushti leading to disturb state of twak and dryness

observed (P< 0.03).

Mamsahara, Agni & Staging:-

The mamsahara taken by patients in Agni viruddha state leads to tridosha

prakopa and rasa dhatu dushti (P < 0.00).

Mamsahara, Urine Protein & Stage:-

The mamsahara and protein loss is significantly observed in stage 5. The

mamsahara is non significant for urine protein in 1 to 4 stages in patients observed

(P< 0.04).

Mamsahara, Agni & Staging:-

While stage 1 to 4 the test is non significant. As the state of agni & dhatu

kshaya is in progression with agni dushti. This is observed in stage 5 significantly.

Page | 137


Chhardi, Anannabhilasha & staging:-

The Chhardi Anannabhilasha is significant for 2 to 4 stages P< 0.01 while

stage 1 to 5 Chhardi Anannabhilasha are non significant.

Chhardi, Shotha & Abhishyandi:-

The abhishyandi sevana is significantly present in Chhardi & Shotha. The

abhishyandi is dushti hetu for kapha and pitta dosha (P < 0.03).

Chhardi, Anannabhilasha & Agni:-

The Sama Agni patient Anannabhilasha is significant P < 0.00 while manda

agni patients Anannabhilasha is P< 0.01 significantly observed.

Chhardi, Anannabhilasha & Abhyvaran:-

When Abhyvaran Shakti is prakrut, Chhardi and Anannabhilasha is P< 0.00.

Madhur, Lavana, Amla and Staging:-

In stage 5, Amla and Lavana rasa are observed significant P<0.03. However

it suggests kaphakara ahara leads to the GFR reduction the Lavana rasa is for pitta

dushti and rakta dushti as well Amla rasa is causative factor for mamsadaha and

shaethilaya.

Anemia, Shotha, Anannabhilasha & stage:-

The Shotha absent and Anannabhilasha present group is significant P < 0.04.

The rakta dhatu dushti along with rasa dhatu is observed. The rasa mala kapha and

rakta mala pitta with Agni dushti is observed for shotha Anannabhilasha lakshna.

Anemia, Anannabhilasha, Chhardi & stage:-

The Chhardi absent and Anannabhilasha present is significantly observed in

Anemia and CKD staging P < 0.02. The Chhardi and Anannabhilasha is non

significant in Anemia CKD staging 0.18.

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