NEPHROTIC SYNDROME IN CHILDREN – A WALK THROUGH AYURVEDIC VIEW

Dr.Anu Shree¹, Dr.Naraan Pai B², Dr.Jithesh Chowta³

¹PG Scholar, Department of P.G. Studies in Kaumarabhritya, Alva’s Ayurveda Medical College, Moodbidri.

²Associate Professor, Department of P.G. Studies in Kaumarabhritya, Alva’s Ayurveda Medical College, Moodbidri.

³Assistant Professor, Department of P.G. Studies in Kaumarabhritya, Alva’s Ayurveda Medical College, Moodbidri.

Abstract:

Nephrotic Syndrome is a common systemic often relapsing illness found by most of the paediatricians in their clinical practice. The clinical and biochemical features of  Nephrotic Syndrome results from the loss of large amount of protein in urine. About 90% of children suffer from most common form i.e. Idiopathic Nephrotic Syndrome which shows insignificant glomerular abnormalities on light microscopy (MCNS). There is no direct reference regarding Nephrotic Syndrome in Ayurveda but can be interpret its pathogenesis under the context of Ojas and Ama. Therefore an outcome has improved with Ayurvedic management. Hence, here an attempt is made to understand the Nephrotic Syndrome in children from Ayuveda point of view for its better management.

Keywords:  Nephrotic Syndrome, idiopathic Nephrotic Syndrome, MCNS,  Ojas, Ama, Ayurveda.

Introduction:

Nephrotic syndrome is primarily a paediatric disorder and is 15 times more common in children than in adults. The incidence is 2-3/1, 00,000 children per year.¹ Among this about 90% of children with Nephrotic Syndrome have Idiopathic Nephrotic Syndrome also known as Primary Nephrotic Syndrome. The international study of kidney disease in children found minimal change diseases in 76.6% of children with primary Nephrotic syndrome which is usually between the age of 2-5 years and more common in boys.²

A clinical picture of Nephrotic Syndrome is characterised by proteinuria (urine protein excretion >40mg/m2/hr), hypoalbuminemia (serum protein <2.5g/dL), hyperlipidemia (serum cholesterol >200mg/dl) and presence of edema.³

Nephrotic Syndrome is not directly mentioned in Ayurveda. Acharyas says any disease even if not described in ancient text can be managed by applying fundamental principles of Ayurveda related to its pathogenesis.  Most of the studies point it towards immunologic base hence it can be considered under autoimmune disorders and can be very well compared with the concept of Aberrations of Ojas in Ayurveda.

Aims and Objectives:

The aim of this study is to understand the Nephrotic Syndrome especially Minimal change nephrotic syndrome (MCNS) in children from Ayurvedic point of view and its better management through Ayurveda.

Materials and Methods:

Different Ayurvedic classical textbooks, modern textbooks, research papers and journals were referred.

Concept of Ojas:

Balya avastha is the stage where Kapha is dominant, meantime functionally underdeveloped and on the process of development.⁴ In Ayurveda Bala (immunity) is described under two context one is Vyadhikshamatva and another one is Ojas. Acharya Charaka had mentioned Ojas as Prakruta Kapha i.e. normalcy state of Kapha and its instability leads to certain fluctuation in immune system.⁵ These fluctuation results into Autoimmune disorder.

Pathophysiology of MCNS:

In children, immunity is determined by the Kapha which in turn is dependent on digestion. Digestion is the process which occurs with the help of various enzymes and secretion resembling Agni includes Jataragni, Dhatwagni and Bhutagni. This leads to healthy and strong Dhatus.

Any disruption in this process results into the formation of Ama which is the main cause for all diseases as mentioned by Acharya Charaka.⁶ This Ama present at GIT level as well as cellular level which means Dhatwagni is related to cellular metabolism and intracellular enzymatic process. This leads to Dhatu Agnimandya which occurs at Medodusti level involving Medovaha srotas and its moola is Vrukka and Vapavahana. When Dhatu Agnimandya is present then Dhatu vriddhi will occur which is abnormal i.e. extra collection of immune complexes over basement membrane.

If this Ama is not cleared then it gets converted into Amavisha which is toxic, insoluble and exerts antigenic effects over the immune system leading to different exaggerated immune response. This response is the cause for glomerular damage leading to pathology of Minimal change nephrotic syndrome.

Aberrations of Ojas v/s MCNS:

In Ayurveda, Acharya Sushruta discussed about three specific aberrations or abnormalities of Ojas.⁷ these three states or abnormalities are considered as three categories of immune disorders.

1. Ojo Visramsa – Displacement of Ojas from its own site which shows the following symptoms.
2. Sandhi Vishlesha = Inability of sandhi i.e. sleshma kapha is dearranged.
3. Gatra sadana = Due to protein loss.
4. Dosha chyavana = Migration of vitiated dosha to other site.
5. Kriya sannirodha = Exercise intolerance, dyspnea etc, because of oedema.
6. Ojo Vyapat – Ojas get vitiated by Dusta Dosha and Dushya, shows the symptoms as follows.
7. Stabdha = Restricted body movements, stiff, firm.
8. Guru gatrata = Weight gain due to disturbed fat metabolism or collection of fluid.
9. Vata shopha = May be generalised pitting type of oedema.
10. Varna bheda = Glossy, shinny look.
11. Glani = Discomfort physically and psychologically.
12. Tradra = Altered consciousness in later stage.
13. Ojo Kshaya – Stage of immunodeficiency. In MCNS Ojokshaya is not there as a cause of Nephrotic Syndrome but it will present if patient took steroids for longer duration then he may enters in stage of Ojokshaya as they cause immune suppression.

Treatment:

Ayurveda is a medical system using complex treatment approaches. Combination of different treatment elements exerts synergistic effects and is benevolent for the outcome. Therefore a multi-modal Ayurvedic treatment has been selected in the management of Minimal change Nephrotic syndrome.

1. Ama Pachana – First line of treatment.
2. Ojo Vyapat hara Chikitsa.
3. Medovaha srotodusti hara Chikitsa.
4. Yakrut uttejaka drugs – To increase the liver function.
5. Rasayana – For regeneration of damage tissues.
6. Protein supplementation.
7. Correction of food habits and life style.
8. Psychological treatment.

Discussion:

Observation suggests that Nephrotic Syndrome is a chronic, relapsing renal disease commonly seen in paediatric practice having a risk of systemic infection, renal insufficiency and many other complications. According to Ayurveda though all Tridosha as well as Dushya (Rasa, Rakta, Udaka, Mutra and Oja) are involved, Kapha and Vata are more aggravated in this disease. Literature suggests Nephrotic Syndrome may be consequence of primary glomerular defect or an immunological abnormality which comes under the broad heading of Ama. In Ayurveda it can be managed by two ways, firstly eradicate the cause for disease; secondly treatment of disease through the drugs which are helpful to reduce the symptoms as well as regenerate the damage tissues. Along with this following Dinacharya and Ritucharya for its prevention in future.

Limitations:

1. Case of Nephrotic syndrome which are in end stage.
2. Cases which are not in position to withdraw the steroids due to risk of relapse.
3. Child less than 2 years due to limitation in administration of medicines.
4. Cases associated with other pathology of urinary tract.

Conclusion:

Minimal change Nephrotic syndrome most common type of Idiopathic Nephrotic Syndrome is associated with complex disturbance in immune system. Number of  immune modulators and immune suppressants have been used for the management of Nephrotic syndrome. But these drugs have potential harmful side effects, hence herbal immune modulator and nephro protective drugs can be adopted for its management.

References:

1. Recent Advances in Pediatrics-20 Hot topics by Suraj Gupte, published by JAYPEE Brothers Medical Publishers (P) Ltd., Edition : 2011, Chapter 3, Page no.44.
2. International study of kidney diseases in children. Nephrotic syndrome in children: Prediction of histopathology from clinical and laboratory characteristics at time of diagnosis. Kidney Int 1978;13:150-165.
3. Paediatrics for practitioner chief editor Sharad Thora and VP Goswami, published by JAYPEE Brothers Medical Publishers (P) Ltd., Edition : 2014, Chapter 51, Page no.367.
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6. Agnivesha, Charaka Samhita edited with ‘Caraka-Chandrika’ Hindi commentary along with special deliberation and appendices etc. By Dr. Brahmanand Tripathi, published by Chaukhamba Surbharati Prakashan Varanasi, Edition:2016, Chikitsa Sthana, Chapter 15, Shloka no.04, Page no.550.
7. Sushruta, Sushruta Samhita edited with Ayurveda-tattva-sandipika hindi commentary by Kaviraja Ambikadutta Shastri, Published by Chaukambha Sanskrit Sansthan. Varanasi, Edition: Reprint 2015, Sutra Sthana, Chapter 15, Shloka no.29, Page no.80.