Section 9: Chronic Nephritis Is Not Simply a Theory of Kidney Deficiency
Chronic nephritis is one of the common clinical diseases, with relatively complex etiology and pathogenesis. However, clinically, it is often considered to be mainly caused by kidney deficiency, or it is believed that on the basis of kidney deficiency, damp-heat, blood stasis, and qi stagnation are also involved, and treatment often revolves around tonifying the kidneys. Based on many years of clinical experience, the author believes that nephritis is by no means simply kidney deficiency. Here, the author’s preliminary insights are shared for colleagues’ reference.
(1) Differences in Syndrome Differentiation and Treatment between Kidney Deficiency and Nephritis
In traditional Chinese medicine (TCM), kidney deficiency includes insufficiencies of kidney yin, kidney yang, kidney essence, brain, marrow, and bones, manifesting as soreness and weakness of the waist and legs, impotence, premature ejaculation, seminal emission, hemorrhoids, etc. Diagnostically, it presents with deep, weak, slow, and soft pulses; pale, fat tongue with white, smooth coating; pale tongue body with teeth marks; night sweats and aversion to cold; loose stools; preference for warmth. In summary, it is all a display of deficiency and insufficiency.
Modern medicine mainly regards nephritis as an inflammatory change of the bilateral glomeruli, essentially an immune disease. Diagnostically, protein, casts, red blood cells, white blood cells, and epithelial cells are found in the urine, or blood creatinine and urea nitrogen are elevated. So how to differentiate syndromes in clinical manifestations of nephritis? This is the key to determining therapeutic efficacy. Through clinical experience, chronic nephritis, even developing into uremia stage, mostly shows wiry, thin, smooth, rapid pulses, especially pronounced deep pulses; red and dark dry tongue; irritability and restlessness; dry stools; accompanied by fatigue and weakness, or pale and smooth tongue, sometimes lower limb edema, poor appetite, etc. If confined by preconceived notions, failing to carefully and thoroughly examine these manifestations, focusing only on pale smooth tongue, lower limb edema, poor appetite, and generally considering nephritis as kidney deficiency, it can easily be misdiagnosed as spleen and kidney yang deficiency and treated with formulas such as Bawei Wan (Eight-Ingredient Pill). This is akin to pouring water on burning fire, with no hope of recovery.
A deep pulse signifies internal disease; a deep pulse is also a pulse of qi, and the pulse reflects water pathogenic factors accumulating. A deep, slippery, or soft pulse indicates dampness, turbid phlegm, and fluid retention. If nephritis patients have deep slippery pulses, it reflects phlegm-fluid damp stagnation accumulating in the middle burner or lower burner; if pressed, the pulse is wiry, thin, smooth, and rapid. The wiry pulse indicates liver qi stagnation; the slippery rapid pulse indicates phlegm and fire stagnation; the thin pulse indicates yin damage. Therefore, even with firm pressure, the feeling of wiry, thin, smooth, rapid pulse remains, essentially reflecting unresolved liver qi and phlegm-fire stagnation internally. Combined with crimson dry tongue with prickles, irritability, frequent dreams, and dry stools, it can be diagnosed as internal heat stagnation. Damp stagnation causes qi mechanism obstruction, poor circulation of qi and blood throughout the body, and disharmony of the meridians, causing fatigue and lumbar pain; internal damp stagnation obstructs qi mechanisms and leads to abnormal bowel transmission, hence loose stools, which are absolutely not due to spleen or kidney deficiency and should not be treated according to deficiency. This is a manifestation of dampness stagnation. Thus, dampness stagnation and kidney deficiency cannot be conflated. In summary, syndrome differentiation focuses on internal heat stagnation and damp obstruction, a complex mixture of damp-heat with no simple major or minor factors. Heat stagnation is clear and transparent; damp obstruction is fragrant and transforming. Treatment with Bawei (Eight-Ingredient) or Liuwei (Six-Ingredient) formulas as tonics is counterproductive and useless.
The author once mentioned in “Wenkui’s Pulse Studies”: “In treating chronic nephritis, at an unknown time, treatment became solely focused on tonifying the kidney, using formulas like Liuwei, Bawei, Zuo Gui, You Gui… The philosophy was to tonify the root and warm the life gate, but can this method really resolve kidney inflammation? Generally, for long-term illness of several years, yang qi is definitely deficient, and edema persists, so tonification to benefit qi, strengthen the middle, and tonify the root is used, mostly with ginseng, astragalus, cinnamon, prepared aconite, and then Erxian Decoction, etc. Shaoqin often found the pulses fine, small, wiry, or fine, rapid, forceful; tongue thin, lips red, coating dry, crimson tongue body; dry mouth, irritability, restlessness, poor sleep, dry stools.” “Deep and slow pulse, deep and slow but somewhat rapid on pressing, pulse pattern seems internal cold but actually a real pattern, indicating heat stagnation unresolved, or phlegm-turbidity blocking qi mechanism; treat by unblocking stagnation and resolving phlegm.” Clearly, heat stagnation in yin portion, why abandon pulse diagnosis to tonify the root and warm the life gate? Clinically, whenever such pulse patterns appear, treatment mostly uses cool and sweet medicinal herbs that nourish yin, adding small amounts of activating blood and dredging collaterals, achieving rapid and effective results. Although chronic illness may have aspects of yang deficiency, clinical medication must be based on objective facts such as pulse, tongue, complexion, and symptoms, not on imagination.
(2) Treatment of Chronic Nephritis
Because edema is the most prominent symptom of chronic nephritis, treatment methods from the “Huangdi Neijing” (Inner Canon) use principles such as “balancing scales, removing old compounds… opening the ghost gate, and cleansing the residences.” The “Jinkui Yaolue” (Essential Prescriptions of the Golden Cabinet) clearly states: “For edema below the waist, promote urination; edema above the waist, induce sweating, then recovery.” Later, formulas such as Bawei and Liuwei to warm and tonify the life gate became prevalent; generally speaking, methods include sweating, promoting urination, nourishing yin, and warming tonification. The author also tried using earth tonification to control water, warming the kidney, removing dampness, sweating, and promoting urination, with medicines such as Bawei Wan, Liuwei Wan, Shenling Baizhu San, Yue Bi Tang, Mahuang Lianqiao Chi Xiao Dou Tang, Wupi Drink, and Zhenwu Tang, but patients’ conditions worsened. This shows that most of us have not broken out of the thinking circle that nephritic edema equals kidney deficiency and have not put enough effort into syndrome differentiation. Instead, we have been obsessive about drug ingredients, hoping special formulas or drugs can cure nephritis, thus treatment fails.
Since the 1970s, the author abandoned old theories, summarizing a complete syndrome differentiation method with remarkable efficacy. In syndrome differentiation, pulse, tongue, complexion, and symptoms must be combined. A slippery and soft pulse, soreness in the waist, general fatigue, and white greasy tongue coating indicate dampness stagnating in qi mechanisms. Irritability, frequent dreams, and dark, short urination indicate internal heat stagnation. Crimson and dry tongue with prickles at the tip indicates heat stagnation affecting the nutritive (ying) level and yin injury. A fat, pale tongue body with a red tip indicates heat stagnation and damp obstruction. Complex and diverse, it is by no means a simple kidney deficiency route and requires emphasis on syndrome differentiation. In treatment, clearing and dispersing heat stagnation, aromatising and transforming damp stagnation, and for heat stagnation with yin injury, simultaneously promoting dispersion and nourishing yin with cool and sweet herbs is important. For damp-heat accumulation in the lower burner, lasting long with involvement of the blood level, focus on clearing and transforming damp heat and cooling blood to dissolve stasis. Overusing warming tonics is undoubtedly harmful and useless.
(3) Discussion on Several Difficulties in Nephritis Treatment
In the treatment process of nephritis, problems such as patients’ diet and uremia treatment are quite tricky. Here the author shares insights for colleagues’ reference.
- Dietary Regulation for Nephritis Patients
Because nephritis results in protein loss through urine, modern medicine emphasizes protein supplementation and consumption of foods rich in protein and fats. However, through many years of clinical experience, the author finds that if protein supplementation is emphasized in TCM treatment of chronic nephritis, efficacy is not evident. All spicy, aromatic, warming, and foods rich in fat and protein should be prohibited, while controlling total food intake to reduce kidney burden, generally not exceeding 250 grams of staple food per day, supplemented with fresh vegetables. Sweet and rich foods increase dampness and generate phlegm; spicy, aromatic, and warming foods often generate fire and injure yin, aggravating heat accumulation and obstructing qi mechanism flow. From modern medical perspective, protein contains nitrogenous compounds, which are mostly excreted via glomerular filtration; overconsumption increases nitrogen and waste production, burdening already diseased kidneys and not providing proper nutritional supplements, adversely affecting recovery. In addition, exercise such as walking two hours daily helps restore kidney nitrogen excretion function. Evidence proves that dietary restrictions and functional exercise play important roles in adjunct drug treatment.
- Treatment of Uremia
Modern medicine has yet to clarify the cause of uremia but believes it relates to immune suppression caused by certain bacterial or viral infections. TCM considers it to be retention of heat evil accumulating deep into the blood level, causing blood vessel stasis. Pathological changes mainly manifest as degeneration and fibrosis of some glomeruli, as well as malnutrition or atrophy of connected renal tubules, corresponding to what TCM calls “stasis.” Depending on the patient’s individual differences, concurrent phlegm-fluid, turbidity, damp-heat, accumulation, and obstruction of qi mechanisms may occur, causing dysfunction of the sanjiao and inability to expel pathogens. Therefore, the method is to cool blood, resolve stasis, and unblock stagnation, commonly using peach kernel, safflower, red peony, licorice, and raw rehmannia to cool blood and resolve stasis. For physically strong patients, 3–5 grams of rhubarb can be added to unblock stagnation and clear damp toxins, often achieving favorable effects.
- Treatment of Vomiting in Uremia
The earliest and most prominent symptom in uremia is often nausea and vomiting caused by retained toxins stimulating the gastrointestinal mucosa, classified under the TCM category of “guan ge” (obstruction pattern). The main cause is failure of clear yang to ascend and turbid yin to descend, presenting as fatigue, drowsiness, nausea, and in severe cases, urine odor in the mouth. Treatment should focus on herbs like perilla flower, substitute hematite, pinellia, and rhubarb, optionally adding aromatic herbs such as agastache and eupatorium to stop vomiting and clear and descend.
- Treatment of High Fever Complications in Uremia
Uremia patients have impaired immune function, making them prone to external pathogenic cold leading to fever. This fever differs from ordinary external fevers. In general external fevers, differentiation focuses on the defensive (wei), qi, nutritive (ying), and blood levels; from slight cold in the wei level to clearing qi, to dispersing heat in ying, to cooling blood for blood conditions, with clear medicating hierarchy. However, fever in uremia is complex, with internal damp obstruction and heat stagnating in the lower burner and external heat evil invading the lung wei. Both upper and lower are affected by evil stagnation, making medication difficult. If urgently treated symptomatically, bitter cold medicines are used to clear heat; but excessive cooling suppresses damp pathogens, aggravating heat and damp obstruction. Thus, medication must both address heat stagnation in lung wei with pungent, cool, and light dispersing herbs like prepared soybean, fried gardenia, peucedanum, apricot kernel, and loquat leaf; and damp stagnation in lower burner with perilla leaf and agastache to open dampness, and madder, moutan, red peony, and rhubarb to clear and descend stasis toxins.