Acute Pyelonephritis management through Ayurveda - A Case Study

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CASE REPORT August 2023 Journal of Ayurveda and Integrated Medical Sciences | August 2023 | Vol. 8 | Issue 8 295 Acute Pyelonephritis management through Ayurveda - A Case Study ABP Raju M.D. in Kayachikitsa, Charaka Ayurveda and Panchakarma Centre, Near Nandyala Check Post Kurnool, Andhra Pradesh, India. I NTRODUCTION Acute Pyelonephritis is inflammation of Renal Pelvis which is Upper Urinary tract infection, most often ascending type of Infection start from urinary bladder, ureter and kidneys. Presents symptoms as classical triad of loin pain, fever, tenderness over kidneys [2] Predisposing factors are bacterial infection (mostly E.coli) urinary tract obstruction, diabetes mellitus, unhygienic genitals. In 80% of the UTI cases E.coli is a largest colonial bacteria and direct reason for the Address for correspondence: Dr. ABP Raju M.D. in Kayachikitsa, Charaka Ayurveda and Panchakarma Centre, Near Nandyala Check Post Kurnool, Andhra Pradesh, India. E-mail: rajubpannaldas@gmail.com Submission Date: 07/06/2023 Accepted Date: 19/07/2023 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.8.8.49 Inflammation of Urinary Tract. Severity of the disease is seen in Young and Elderly People, Prevalence [3] is 15- 17/10,000 females and 3 to 4/10,000 males, females are more commonly affected, 40% of the people require Hospitalization. Treatment includes Antibiotics adequate Hydration and symptomatic support “Institution of specific antibiotics, after identific ation of bacteria by culture followed by sensitivity test, eradicate infections in majority of patients” [4] But not in all. In Ayurveda it is ~ Agantuja Krimiroga, Vastiroga, Mutravahasroto Vikara, and Vrukkavikara and Madhumeha . Madhumeha is three Doshaja Vikara, Sapthadhatus are vitiated because of Agni Dusti , Ama formation and Srotoavarodha seen. Treatment includes, Agantuja Krimi Chikitsa Mutravaha Sroto Vikara Chikitsa, Vasti Chikitsa and Madhumeha Chikitsa. C ASE R EPORT Mr.xxxxxxx, 76/M came to my Clinic, and presented with burning micturition, increased frequency of scanty urination, on and off loin region pain associated with malaise since 2 months. A B S T R A C T The role of Diet, Drugs and Medical attention is very important specially for Elderly People, most probably they were neglected because they need assistance. Modern Science enriched with Antibiotics which are not advisable for a long duration to Elderly, Diabetic & Immune compromised Patients. Even, in Elderly people the Organs are Fragile and most of the Drugs become contraindicated, in such condition Ayurveda is inevitable. Ayurveda explained Tryoupasthambha , Dinacharya, Rutucharya, Aaharaniyama and “Swas thasya Swasthya Rakshnaam Aaturasya Vikara Prsamanaam [1] ” (prevention is better than cure) to preserve the health of healthy individual right from Childhood. Ayurveda plays a crucial role in promoting healthy Body and step forward in treating the disease based on Ayurvedic principles, where there is no role of antibiotics. Here is a case neglecting diet, physical activity and medical attention finally alighted to Diabetes, near prostate obstruction, upper urinary tract infection which agonized him severely. This condition according to Ayurveda~ Vrukkavikara , Mutravaha Srotovikara, Vasti Vikara . All the protocols of Ayurveda Deepana, Paachna, Srotosodhana, Mutrala, Kapha Vatahara, Vata Anulomama, Pittasama Chikitsa, Krimihara Chikitsa Sutra are followed and treated with Chitrakadi Vati , Gokshuradi Kwatha, Diet, Physical exercise and Barley water. Key words: Mutravaha Srotas, Vrukkavikara, Vastivikara, Chitrakadi Vati, Gokshuradi Kwatha, Barley Water

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ABP Raju. Acute Pyelonephritis management through Ayurveda ISSN: 2456-3110 CASE REPORT August 2023 Journal of Ayurveda and Integrated Medical Sciences | August 2023 | Vol. 8 | Issue 8 296 Apparently patient was normal 2 months back gradually developed lack of Appetite, Cold, Fever, Nausea, Vomiting, Burning micturition and increased frequency of Scanty Urination, Loin pain followed by Hiccups. 2 episodes Fever spikes associated with Rigor observed in last 4 weeks. Patient took treatment in different Hospitals for above illness. Tab. Augmentin- 625 mg BD for 14 days, Tab. Nitrofurantoin BD for 14 days, temporarily getting relief. History of past illness Patient was known a case of Diabetes mellitus, Hypertension, he is on Oral Hypoglycemic Agent Tab. Glimepiride 1 gr BD (Metformin is contraindicated as Ser.Creatinine is 2.0) and on Anti Hyper tension medication, Tab. Telsartantrio 1 OD, (Telmisartan 40 mg, Amlodipine Besilate 5 mg and hydrochlorothiazide 12.5 mg) Tab. Clinidepin - 5 mg at night. Even though HbA 1 C is 9.8 pt is not willing to take Insulin. History of Bilateral Prostate Hypertrophy was there but Pt neglected for several years, 2 years back, in almost obstructed condition operated successfully and recovered. CBP - Increased Neutrophils, and Increased TLC count, Chest X-ray with in normal limits, Upper Gastro Intestinal Endoscopy – Grade 2 Gastritis, ECG - with in normal limits, 2 D Echo - Aortic Valve Sclerosis otherwise normal, CUE - Loaded Pus cells, Urine Culture Sensitivity - E.coli bacteria growth is seen, Bloodurea - 58 mg/dl, Serum Createnine - 2.0 mg/dl, Electrolytes - 3.4 m.moles/L, RBS - 410 mg/dl, HBA 1 C is 9.8%, Ultra Sound Abdomen - Bil. Renal Parenchymal Disease, 20*15 cyst noted in Left Kidney. On Examination Patient attending to his daily activities, BP - 160/100 mm.Hg, RBS - 248 mg/dl. No history of Addictions noted. Pt Medical History reveals that - He is suffering with Acute pyelonephritis; Mutravahasroto Vikara and Madhumeha Rogi Pariksha Patient Prakruthi is - KPV. Mamsasaara Purusa, Madhyamakaya Saareera, Madhyama Sattva, Jatharagni and Dhatvagni are in Agnimandhya state, Avara Vyayama Sakthi. 3 Doshas are involved, Medha, Rakth, Sukra, Ambu, Vasa, Lasika, Majja, Rasa, Ojas, Mamsa are Dushyas . Nadi - Dvidoshaja , Mala - Aamayuktha, Mutra - Panduvarna, Phena Yuktha Snigtha , Jihwa - Malayuktha, Sparsha - Parikasha Sitala Sparsha. Sthanasramsraya at Vasti Sthana and all Srotas of Dushyas as mentioned above are involved in addition to Swedovahasrotas and Mutravahasrotas . Roga Pariksha As evident of Mamsa, Raktha Dhatu Dusti and Mutravahasroto Vikara , there is a slight raise in the Serum Creatinine which is considered as one among Vrukka Vikara in Western, Medicine. From Roga Purva Vruttanta it is clear that Patient suffered with Vatastila (BPH), this lead to Mutravahasroto Avarodha, this aid Sanchaya of Agantuja Krimi (E.coli) at Vastisthana , [similar to Asyapakarsana, Dosha landed at favourable place. Gut to UTI and waiting for suitable Prakruthi . Whenever there is High sugar levels ( Prakruthi ) in the Body there is chance of Prakopa (colonisation) of E.coli Bacteria in the Urinary bladder. Depending intensity of Prakopa , the Prasaraavastha of Agantujakrimi took Adhogamana and Aama to (~inflamatory cytokines) [5] Urdhwa Gamana to conclude Sthanasramsrayam at Vrukka causing Vrukka Roga, and Mutravahasroto Vikara (pyelonephritis). The Vurdhwa Gamana of Aama was assisted by Apanavata which is in Avarodha & Pratimargagamana avastha. Mmadhumeha was a preexisting Disease. The treatment planned for the patient is Deepana Pachana and Kapha Vatahara, Vata Anulomana , and Pitta-Sama Chikitsa. Mutra Pravahana and Krimi Roga Chikitsa Sutra are used 1 Chitrakadivati [6] 1 BD for 1 Month. 2 Gokshuradi (Sariva, Dhanyaka, Punarnava) Kwatha 40 ml. 3. Diet for Blood sugar management (Cereals) as mentioned in Ch.Chi.Pramehadhyaya 4 Yava specially used as mentioned in Prameha Adhyaya [7] Advised to continue anti HTN Drugs and OHA Drugs, but asked to stop antibiotics, (Tab.Nitrofurantoin 1 OD for next 1 month). The classical preparation of

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ABP Raju. Acute Pyelonephritis management through Ayurveda ISSN: 2456-3110 CASE REPORT August 2023 Journal of Ayurveda and Integrated Medical Sciences | August 2023 | Vol. 8 | Issue 8 297 Chitrkadi Vati from Cha.Sam.Chi. Grahani Adhyaya given orally with a sip of Luke warm water 1 tab in the morning on empty Stomach & 1 tab before Dinner to stimulate Jatharagni , and for Aamapachana which in turn stimulate Dhatwagni, Bhutagni, thereby Srotas are cleared from obstruction attain crystal clear Srotas . Assessment criteria includes Loin pain, Fever, Tenderness over kidneys, CBP, CUE, RFT Grade Loin pain Tenderness on kidney region 1 No pain Tenderness not found 2 Mild pain allows palpation frequently Mild tenderness allows palpation 3 Moderate pain - usually does not allow palpation Moderate tenderness winces on palpation 4 Sever pain never allow palpation Severe tenderness Never allow palpation CUE grading Grade Frequency Burning sensation Pus cells U. Sugar U. Albumin I 4 times/24 hrs No burning sensation 1-2 HPF nil nil II 5 to 10 times/ 24 hrs Mild, and only during urinating 3-9 HPF + + III 11 to 16 times/24 hrs During and after urination 10- 20 HPF +++ ++ IV More than 16 times Continuous burning sensation plenty >4+ >+++ Fever grade Grade 1 2 3 4 Fever 98.6°F 98.7-100°F 101-103°F 104°F & above Aki grading Aki grade Ser.creat Blood urea GFR/2 lit of water potassiu m I <1.6 mg/ dl 10- 40 mg/d l 0.5 ml/kg/hr/6 hrs 3.5- 5.5 mmol/ L II 1.7- 2.5 mg/dl 41- 59 mg/d l 0.5 ml/kg/hr/12 h rs 5.5- 5.9 mmol/ L III 2.6- 5.0 mg/dl 60- 79 mg/d l 0.3 ml/kg/hr/24 h rs 6.0- 6.4 mmol/ L IV 5.1- 10 mg/dl 80- 99 mg/d l Anuria for 12 hrs 6.5- 6.9 mmol/ L V (ESRD ) >10 mg/dl >100 Anuria for 24 hrs >6.9 Gokshuradi Kwatha drugs properties in Ayurveda and in research view Drug Ayurveda Research Gokshura [ 8] Mutrakrcchra, Mutrala, Sothahara, Pramehahara Nephroprotective, Diuretic activity Punarnava [9] Kapha Vataharam Sothahara, Diuretic, Mutrala Reduces blood urea, Haematic effect, anti-inflammatory activity, useful in Neproticsyndrome, antioxidant Sariva [10] Tridoshahara, Jwarahara Increases UOP, antiinflammatory, anti-bacterial, against E.coli Dhanyaka [11] Tridoshahara, Amavata Jwarahara Anti inflammatory The useful parts of the above mentioned plants for Kwatha are taken in Dry Coarse Power of each 1 Part and 16 parts of water. On a low flame boiled till 1/4 th of water remains in the container, Filtered and 40 ml of

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ABP Raju. Acute Pyelonephritis management through Ayurveda ISSN: 2456-3110 CASE REPORT August 2023 Journal of Ayurveda and Integrated Medical Sciences | August 2023 | Vol. 8 | Issue 8 298 the filtered Kwatha given internally BD. After 3 days as the evening dose, it is disturbing patient sleep during night, evening dose was De-escalated to 20 ml OD till further orders. Yava (Barley) ~ 100 gms taken cleaned with normal water and boiled with 200 ml of Water until 100 ml of water remain in the container, filtered and 100 ml given daily to attain Mutravahasroto Sodhana & Vasti Sodhana. Diet for blood sugar management with Cereals and Barley advised according to Prameha Chikitsa in Charaka Samhita Chikitsa Sthana. Patient made a Habit taking Barley as regular Diet. As days are passing High Sugar level came into control because of Diet control. Serum creatinine and Burning sensation of urine has significantly reduced because of Kwatha [12] After 12 days the dose of Chitrakadi Vati reduced to 1 OD. The Kwatha changed to 40 ml OD. Advised to take Luke warm water till further orders. The treatment continued for next 8 days. Though there is an immediate effect like decrease in Ser. Creatinine but the treatment continued to stop colonization E.coli bacteria in Bladder. O BSERVATIONS AND R ESULTS Finally, by the completion of treatment Pt was on anti HTN Drugs, Tab Glimepiride 1 gr BD, Barley Water (Diet). Once again investigations done, On examination Pt Mentally Physically active. No fresh complaints noted, Appetite is Good BP:140/80. RBS - 170, complete kidney screening found as Ser.Creatinine - 1.2, Blood Urea - 38, Electrolytes with in normal limits, UOP: was Normal - in Colour, Quantity, Frequency, Stream line flow, Pus cells 2-4, Urine Sugar - Nil and Urine Albumin - Nil, pain, burning sensation was not found while urinating. DISCUSSION Patient neglected Prostate Enlargement for several Years, High Sugar levels are two major predisposing factors for colonization of E.coli Bacteria in Urinary Bladder. E.coli is the most common Bacteria causing Acute Pyelonephritis due to its unique ability to adhere to Urinary tract and Kidneys. E coli has adhesive molecule called P-fimbriae [13] which interact with Receptors on the surface of the Uroepithelial cells, which leads to Infection, Hypoxia, Ischemia, Inflammatory Cytokines, Bacterial toxins, and other reactive processes further lead to completion of Acute pyelonephritis [14],[15] Chitrakadi Vati is mainly indicated for Agnideepaka, Amapachaka and Vatanulomaka . Here the drug is used to stimulate Jatharagni, Dhatwagni, Bhutagni so that Kapha Kledhana Vichedana Vilayana Kapha Vata Anulomana, Vanulomana is attained. The obstructed Srotas are cleared which allows the action of Drugs and Diet their by facilitate the possibility recovery. The Kwatha is drug combination having multi-dimensional properties. Gokshura is moderate Diuretic [16] Punarnava in Ayurveda is defined as the Drug which regenerates i.e., it Rejuvenates affected part or aids regeneration of new cells so the Infected or Injured sites are repaired. Punarnava is an effective Kaphavata Hara Dravya [17] Sariva is the drug that encounters E.coli bacteria at P-Fimbrae and wont allow to adhere to the Uroepithelial cell [18] Collectively Gokshura, Punarnava and Sariva are ~Diuretics facilitate free flow of Urine to flush out E.coli. Punarnava, Sariva, Dhanyaka are anti Inflammatory which are meant to reduce Inflammatory condition at Upper Urinary tract level so the Glomerular filtration run promptly there by Creatinine level came down. Apakarsana means removal of Krimi it is attained by flow of Urine in Urinary Tract. Nidana Parivarjana is attained TURP Surgery and by closely monitoring Sugar levels, Prakruthi Vighatana is done by lowering the body sugar levels, once low sugar levels are maintained in the body, the E.coli colony starved for food and there by arrested its spread, follows decline in infection and Inflammatory response. Observation Grade BT Grade AT Flank pain 2 1 Tenderness 2 1 Fever 3 1 CUE Pus cells 4 1 Frequency 3 1

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ABP Raju. Acute Pyelonephritis management through Ayurveda ISSN: 2456-3110 CASE REPORT August 2023 Journal of Ayurveda and Integrated Medical Sciences | August 2023 | Vol. 8 | Issue 8 299 Albumine 3 1 Sugar 4 1 Blood +ve -ve KFT Blood urea 2 1 Ser.creatinine 2 1 CBP Wbc 17,200 cells/cumm 8,500 cells/cumm Neutrophills 83% 68% RBS 410 mg/dl 126 mg/dl HbA 1 C 9.8 9.0 CONCLUSION Gokshuradi Kwatha is a proved drug combination of kidney function, Urinary tract infection in Ayurvedic Classics, but it needs precise study at the cellular level, and specific classification of drug action. The present study is a single case study so we can’t come to fina l conclusion, it need study on large sample size. REFERENCES 1 Acharya Yadavji trikamji. Charaka Samhita of Agnivesha, Chakrapanidatta Ayurveda Deepika (Sanskrit), Sutrasthana 30/26, Chaukambha Sanskrit series Office, Varanasi, Edition reprint-2011 2 Davidsons Principles of Internal medicine, Nephrology and Urology, Edition-23 rd, London Elsevier 2018, page 430 3 https://www.ncbi.nlm.nih.gov/books/NBK 519537/ 4 Harshmohan, Text book of pathology, The kidney and lower urinary tract, New delhi Jaypee, Edition-4 th , page-666 5 Davidsons Principles of Internal medicine, Nephrology and Urology, Edition-23 rd, London Elsevier 2018, page 430 6 Acharya Yadavji trikamji. Charaka Samhita of Agnivesha, Chakrapanidatta Ayurveda Deepika (Sanskrit), Chikitsasthana 15/97-98, Chaukambha Sanskrit series Office, Varanasi, Edition reprint-2011 7 Acharya Yadavji trikamji. Charaka Samhita of Agnivesha, Chakrapanidatta Ayurveda Deepika (Sanskrit), Chikitsasthana 06/21-24, Chaukambha Sanskrit series Office, Varanasi, Edition reprint-2011 8 JLNSastry, Dravyagunavignana Volume-2 English translation, Published by Chaukambha Orientalia, Edition 2010, page-98 9 JLNSastry, Dravyagunavignana Volume-2 English translation, Published by Chaukambha Orientalia, Edition 2010, page-437 10 JLNSastry, Dravyagunavignana Volume-2 English translation, published by Chaukambha Orientalia, Edition 2010, page-348 11 JLNSastry, Dravyagunavignana Volume-2 English translation, published by Chaukambha Orientalia, Edition 2010, page-264 12 JLNSastry, Dravyagunavignana Volume-2 English translation, Published by Chaukambha orientalia, Edition 2010, page-101 13 https://www.ncbi.nlm.nih.gov/books/NBK 519537/ 14 Davidsons Principles of Internal medicine, Nephrology and Urology, Edition-23 rd, London Elsevier 2018, page 430 15 Harshmohan, Text book of pathology, The kidney and lower urinary tract, Newdelhi Jaypee, Edition-4 th , page-666 16 JLSastry, Dravyagunavignana, Volume-2, English translation, Published by Chaukambha Orientalia, Edition 2010, page-98 17 JLNSastry, Dravyagunavignana, Volume-2, English translation, Published by Chaukambha Orientalia, Edition 2010, page-438 18 JLN Sastry, Dravyagunavignana Volume-2, English translation, published by Chaukambha Orientalia, Edition 2010, page-350 ******************************* How to cite this article: ABP Raju. Acute Pyelonephritis management through Ayurveda - A Case Study. J Ayurveda Integr Med Sci 2023;08:295-299. http://dx.doi.org/10.21760/jaims.8.8.49 Source of Support: Nil, Conflict of Interest: None declared. Copyright © 2023 The Author(s); Published by Maharshi Charaka Ayurveda Organization, Vijayapur (Regd). This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc-sa/4.0), which permits unrestricted use, distribution, and perform the work and make derivative works based on it only for non-commercial purposes, provided the original work is properly cited

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Ayurveda, Jatharagni, Sariva, Punarnava, Dhanyaka, Gokshura, Agnidushti, Bhutagni, Charakasamhita, Barley-water, Fever, Urine, Diabetes mellitus, Bacterial infection, Tenderness, Scanty urination, Chitrakadi Vati, Urinary tract, Serum Creatinine, Agnideepaka, Deepana Pachana, Dhatwagni, Ama formation, Blood sugar, Vasti Chikitsa, Aamapachana, Blood urea, Urinary tract infection, Burning micturition, Albumin, Urine sugar, Kidney function, E. coli, Prakruthi, Acute pyelonephritis, Amapachaka, Srotoavarodha, Mutravaha srota, Vata Anulomana, Kapha-Vatahara, Pus cells, Madhumeha chikitsa, Prameha Chikitsa, Urine Albumin, Vatanulomaka, Flank Pain, Urinary tract obstruction, Kidney, Prostate enlargement, Frequency, HbA 1 c, E.coli, Gokshuradi Kwatha.