Section 11: Experience with Traditional Chinese Medicine Treatment for Uremia
Uremia is the most severe stage of chronic renal insufficiency, characterized mainly by declining renal function, retention of metabolic waste products, and disturbances in water, electrolyte, and acid-base balance. Common indicators include a glomerular filtration rate below 25 ml/min, blood urea nitrogen greater than 21.4 mmol/L, and serum creatinine greater than 442 μmol/L. Clinical symptoms are quite complex, such as dull complexion, foul breath, edema with poor appetite, nausea and vomiting, urinary obstruction, itching skin, bleeding, and mental confusion. In Traditional Chinese Medicine (TCM), this condition is generally categorized under “Guan Ge” syndrome. Treatment is often quite challenging due to the mix of yin and yang disorders, as well as the confusion of deficiency and excess patterns. Here, clinical insights are shared to discuss the differentiation and treatment experiences.
(1) Analysis of fatigue symptom from the perspective of TCM syndrome differentiation
Mental fatigue and physical weakness are neurological manifestations of uremia. It is generally thought that chronic illness leads to deficiency, and since uremia is a severe renal failure, many practitioners unilaterally apply warming and tonic herbs expecting effective results. From my personal clinical experience, overusing warming tonics can worsen fatigue, and may cause symptoms like agitation, frequent dreaming, dark urine, gum bleeding, red and thin tongue, and wiry, thin, slippery, rapid pulse. The root cause often lies in neglecting the combined reference of pulse, tongue, color, and symptoms in TCM diagnostics. One must look beyond the complicated surface phenomena to grasp the essence of the disease. Fatigue with body heaviness shows a floating pulse that becomes soft when pressed gently, and a wiry, thin, slippery, rapid pulse when pressed deeply. The wiry pulse indicates blood stagnation, the thin pulse indicates yin damage, rapid pulse indicates heat, and slippery pulse suggests phlegm-damp obstruction. Together, they indicate dampness obstructing the qi and blood with heat stagnation. Some patients have a floating pulse that is soft and weak in the middle, but a deep slippery rapid pulse. Analyzing only the weakness may suggest qi insufficiency, but the slippery rapid pulse indicates phlegm-damp accumulation internally and heat closure. Thus, this weak pulse suggests an internal heat closure pattern caused by dampness obstructing the qi level. Their tongue is dark red with a slippery greasy coating, indicating yang qi weakness, damp obstruction of qi movement, and internal heat stagnation. If only warming tonics are used, won’t that exacerbate the heat stagnation and damp retention? Therefore, careful pulse analysis is essential to accurately understand the pathological mechanism of heat stagnation with dampness obstruction.
(2) Analysis of severe itching of the skin
Yin injury and dehydration cause skin to lose luster, become dry, and desquamate. Urea excreted through sweat glands crystallizes into white crystals called urea frost that irritates the skin, causing uremic dermatitis. Patients feel intense itchiness that causes scratching; skin breakdown leads to secondary infections. The tongue coating is often slippery and greasy, with a deep red tongue body or red tip and edges with prickles appearing. Tongue coating mainly reflects qi function disorders, and tongue body indicates the nature of the disease. Slippery greasy coating suggests dampness obstructing the qi level; a deep red tongue indicates heat in the blood level, confirming heat presence. The pulse is slippery and rapid; with a wiry and hurried rhythm when pressed, representing phlegm and liver qi stagnation with heat. The irritability and agitation indicate heat disturbing the heart. Women may have dark, heavy, early menstruation due to heat forcing the blood prematurely. Overall, this indicates heat stagnation in the blood, dampness obstructing the qi, requiring treatment that addresses both aspects.
(3) Discussion on anemia
Anemia is a necessary symptom in uremia patients, manifested by decreased hemoglobin and dizziness. It is commonly believed anemia needs supplementation, which is easy to think of: one is dietary nutrition with high fat and protein foods; two is medicinal supplementation including warming, nourishing, and greasy substances such as ginseng, aconite, astragalus, and deer antler. But the result is often a sharp rise in blood urea nitrogen and creatinine, while hemoglobin further decreases. In fact, during uremia, severe renal failure means intake of protein and fat-rich high energy foods only worsens heat stagnation and increases renal excretion burden, causing deterioration. I advocate dietary control, with patients mainly on vegetarian diet, more walking, and avoiding spicy, fatty, and protein-rich foods. This actually raises hemoglobin and lowers blood urea nitrogen, which has been proven in many years of clinical treatment.
(4) Analysis of edema symptoms
Due to reduced renal water-excreting capacity, edema is common, persistent for years, and difficult to resolve. How to differentiate and treat edema? Should one strengthen kidney yang with Zhenwu decoction or use Wuling powder to promote mild diuresis? My clinical experience: the more diuretic, the worse the edema; the more nourishing, the more complex the symptoms become. Observing patients, a pale yellow or dull complexion is common. Yellow is the soil color, and dampness is associated with earth element; dampness blocks internally, yang qi fails to ascend, and qi and blood fail to nourish the face, so complexion becomes yellowish and dull. The tongue is large, swollen with teeth marks, smooth surface—indicating yang deficiency and qi weakness. Yet tongue body leans toward red with tip prickles and red, dry lips, indicating latent heat in the heart and liver meridians. Thick coating is present, with phlegm damp obstruction. The pulse is mostly soft and slippery but becomes wiry and rapid on deep examination. Soft indicates damp pulse, caused by water retention and phlegm turbidity; wiry rapid indicates heart and liver qi stagnation with heat. Thus, this pattern is dampness obstructing the qi level with heart-liver heat, qi and yin deficiency, not a simple deficiency or excess. Treatment with lung-dispersing exterior-releasing and blood-cooling heat-clearing herbs yields remarkable results. Dispersing the lung exterior resolves damp stagnation and opens water pathways (the so-called “opening the upper sluice gate”); cooling heat in the blood dissipates heart-liver fire, effectively handling the problem from both ends quickly.
(5) Analysis of vomiting symptoms
Gastrointestinal symptoms are the earliest and most prominent symptoms of uremia, initially characterized by loss of appetite and abdominal discomfort, followed by nausea, vomiting, glossitis, foul mouth odor, and oral ulcers. The cause is the retention of toxic substances affecting the nervous system, and their breakdown products irritating the gastrointestinal mucosa, causing dysfunction, widespread mucosal inflammation, and ulcers. Vomitus tastes sour and bitter with urgent retching. TCM diagnosis is “heat stagnation in the stomach,” causing loss of stomach harmony and rebellious qi upward leading to vomiting. Also seen are irritability, dry mouth, scanty hot urine, frequent dreaming at night, red tongue, and rapid pulse—all supporting internal heat accumulation. The pathogenesis is internal heat stagnation affecting stomach and intestines, forcing reversed flow resulting in vomiting. Clinically, treatment combines bitter-cold heat clearing and aromatic ascending/downward harmonizing herbs, often yielding good results.
(6) How to lower blood urea nitrogen and creatinine
Blood urea nitrogen and creatinine are key indicators reflecting the degree of kidney function impairment. Clinically, many patients taking warming tonics to benefit qi and nourish yin paradoxically show rising creatinine and blood urea nitrogen and worsening condition. Modern studies suggest two reasons: one, many tonic medicines contain large amounts of amino acids (e.g., Ejiao, deer antler gelatin), and since renal function is already compromised and unable to excrete nitrogenous waste effectively, taking gelatinous tonic herbs increases nitrogen load and non-protein nitrogen in the blood; two, some herbs inhibit organism’s nitrogen excretion (such as Aconite, Cinnamon, and Red Ginseng). Therefore, I use invigorating blood circulation to resolve heat stagnation and clear heat and eliminate dampness to relieve stagnation, resulting in rapid decreases in creatinine and blood urea nitrogen.
(7) Issues related to complications of diabetes
For diabetic patients, increasing protein is considered the treatment direction, medications focus on supplementing and tonifying downward, benefiting qi and ascending yang. Long-term disease frequently leads to glomerulosclerosis, nephrosclerosis, and pyelonephritis, called diabetic nephropathy. Later stages show decreased renal function resulting in uremia. Diabetes treatment mainly follows sweet-warm nourishing and sweet-cold tonifying methods. For uremia, excessive use of warming tonics is unfavorable. Hence treatment is difficult. I adopt combined tonification and purgation with differentiated pathways to strengthen qi and nourish deficiency as the root, reduce turbidity and remove toxins as branch treatment. Strict differentiation is essential; mixing patterns easily causes mutual interference and alternating exacerbations.
(8) Discussion on dialysis
Dialysis chiefly reduces nitrogenous retention in the blood. Common methods include colonic dialysis, peritoneal dialysis, hemodialysis, and even kidney transplantation. Although effective, these methods are costly and incurable, not the best solution. While differentiating and treating uremia with TCM, I advocate striving to avoid dialysis; even when patients begin dialysis, treatment should focus on herbal medicine to reduce dialysis frequency or ideally avoid it altogether. I once treated a 65-year-old retired worker with late-stage uremia, blood urea nitrogen 44.3 mmol/L, creatinine 1538 μmol/L, complicated by coronary heart disease and hypertension. Western medicine considered dialysis too risky and advised hospice care. The patient was desperate and sought TCM treatment, inviting me for consultation. At diagnosis, the patient had pale complexion, whole-body edema, poor appetite with vomiting, severe shortness of breath, cold extremities, soft slippery pulse with strength on deep palpation, red tongue with greasy coating. The patient ate rich, greasy food. This indicated dampness obstructing qi level, heat stagnation in blood level. Treatment involved dispelling wind, resolving dampness, cooling blood, and invigorating circulation with Tao Ren Cheng Qi Tang plus added Schizonepeta and Saposhnikovia. After 10 doses, the condition improved significantly and was maintained with this approach. After more than half a year, the patient could travel outdoors, blood urea nitrogen dropped to 12.3 mmol/L, creatinine to 654 μmol/L. This proves TCM can resolve uremia without dialysis. However, this is a very difficult topic requiring ongoing clinical research and discussion.
Treatment of uremia must emphasize syndrome differentiation and treatment, valuing the combined diagnosis of pulse, tongue, color, and symptoms. Expecting a universal remedy or medicine to cure all diseases will inevitably lead to unsatisfactory results in clinical practice and research.