Introduction

Chronic kidney disease (CKD) is a chronic degenerative disease that cannot be successfully treated with Western Medicine. If uncontrolled, the disease may progress to a state called chronic renal failure (CRF). As many as 90,000 Americans develop CRF every year and 20 million Americans currently have CKD. This is a problem all around the world, not just in the USA. In China, rather than using Western medicine, Chinese herbs and acupuncture are a common treatment.

While in China, I trained under Dr. Wang Xiao Zhun, an internal medicine doctor at the Hunan University of Traditional Chinese medicine who is an expert in the treatment of CRF. Dr. Wang’s formulas were able to help her patients maintain healthy lives and manage the disease for years with little or no Western pharmaceutical intervention, dialysis, or kidney transplantation. This paper shares her ideas about herbal medicine.

Background to Chronic Kidney Disease

Chronic kidney disease is the progressive loss of renal function. This condition is systemic and will eventually damage virtually all of the organ systems.1 It develops slowly as the nephrons of the kidney are gradually damaged and glomerular filtration rate decreases, ultimately leading to an advanced state called chronic renal failure. Imbalances in creatinine, urea, potassium, salt and water, do not become apparent until the renal function drops below 25% of normal.

The leading causes of chronic renal failure are diabetes and hypertension.2 However, glomerulonephritis, polycystic kidney disease, obstructive uropathy, and others can also cause CRF. The manifestations are primarily disturbances in electrolyte and fluid balance, removal of wastes and toxins, erthropoitein production, and blood pressure control. 3 Clinical symptoms include polydipsia, polyuria and oliguria. Depending on the stage of decline nocturia, uremia, anorexia or poor appetite, nausea and vomit, diarrhea, weight loss, pruritus, edema, and possible neurological symptoms can also occur.1 Other complications include further contribution to hypertension and anemia from the decline in production of erythrpoietin.

Chinese Medicine Diagnosis and Patterns

CKD and CRF are complex symptom patterns with deficiency as the root cause and excess as the branch manifestation. Primarily, spleen and kidney deficiency are the root cause while blood stasis, heat toxicity, and phelgm turbidity are the branch. “ It is possible the ancient doctors could not treat CKD, because they would only tonify and not treat blood stagnation as well,” Dr. Wang once remarked. “The treatment should focus on tonifying the kidneys, moving blood stagnation, and draining toxicity, but without damaging the kidneys.”

The herbs which damage the kidneys are the herbal species which contain artistolochic acid, such as guang fang ji, ma dou ling, and guan mu tong, that are associated with severe kidney damage. 4 These herbs were part of a notorious weight loss scandal in which physicians caused many of their patients to develop kidney damage.5

An Integrated Medicine Approach

In CKD there is a strong connection between the TCM pattern and modern medical research. After the basic pattern is discovered, the goal of the prescription is to address the root and the branch, creating a balanced treatment for tonifying the deficiency and getting rid of the excess. For the primary condition of kidney deficiency use zhi bai di huang wan. If it is spleen deficiency, use shen ling bai zhu san or wu ling san.

Blood stasis, toxicity, and phlegm turbidity are the primary causes of changes in the glomerular capillary blockage, sclerosis, and ischemia. Phlegm manifestation can be treated with the addition of herbs to transform phlegm and tonify the qi, such as ban xia, bai zhu, and dang shen. Another helpful concept to treat phelgm and dampness excess is the combination of aromatic herbs with cold draining herbs to help digestion and clear excess heat toxicity simultaneously. For example, the classic formula of er miao san combines cang zhu with huang bai to clear damp heat in the lower jiao. This concept can also be applied to the combination of hou po and pu gong ying or huang lian, to open and drain dampness in the middle jiao. Phlegm may manifest on the tongue and pulse, but it may also be apparent only from the hyperlipidemia.

Chronic diseases cause qi vacuity and blood stagnation. The combination of blood movers and qi tonifiers is helpful even when there are no obvious signs of blood stasis or qi vacuity. Huang qi is helpful to further tonify qi and san qi to moisten and move the blood.

The stagnation of blood and phlegm almost always create heat toxicity, which must be drained with cold draining herbs. Da huang is very important for CKD and CRF, to clear toxicity from the fu organs, eliminate dampness, promote blood flow, and remove the blood stasis. Add it to the formula in very small doses as not to over drain and move. Traditionally, da huang is thought to “get rid of the old useless things for the new useful things.” In this case, it is the blood stasis and toxicity are old and useless. Often, da huang can be combined with fu zi, in order to warm the kidney and reduce the cold properties of the da huang.

Conclusion

CRF and CKD are serious diseases that millions of around the world face, however there is currently no cure. Chinese herbs offer hope to these individuals. The focus of the treatment should be to address both the root and the branch in order to create a balanced formula of tonifying the deficiency and getting rid of the excessive.

I would like to thank Dr. Wang Xiao Zhun for the openly sharing her knowledge and experience with me. I would also like to acknowledge Dr. Gary Peng for his help with translation.

1. McCance K, Huether S. Pathophysiology: The Biologic Basis for Disease in Adults And Children Fifth Edition
St Louis: Mosby; 2005.

2. Medline Plus. Chronic Renal Failure Page. 2007. Available at http://www.nlm.nih.gov/medlineplus/ency/article/000471.htm. Accessed on Feb. 15, 2009.

3. Goroll AH, Mulley AG. Primary Care Medicine: Office Evaluation and Management of the Adult Patient
. Philadelphia: Lippincott Williams & Wilkins; 2000.

4. Bensky D, Clavey S, Stoger E. Chinese Herbal Medicine: Materia Medica, Third Edition
Seattle: Eastland Press, Inc; 2004.

5. Mills B, Bone K. The Essential Guide to Herbal Safety. St Louis: Elsevier Churchill Livingstone; 2005.

What makes us different?

There are an overwhelming number of clinical options for the Chinese medicine practitioner to learn and master.  Approaches to treatment vary from country to country, philosophy to philosophy, and doctor to doctor.  When we are looking to improve our clinical skills in general, or address a single patient, it can be hard to find useful information.  TCM Focus will now fill this void as an open access online journal of clinical acupuncture and Chinese medicine.

TCM Focus will serve as a journal and resource where clinicians can share their insights and exchange ideas about how to understand and apply Chinese medicine.  Our main goal is to elucidate the thought process of the clinician through essays and case studies.  We feel that there are already reliable journals for acupuncture and Chinese medicine trials such as Journal of Alternative and Complementary Medicine and the Journal of Traditional Chinese Medicine. There are a small number of quality clinical journals, such as The Lantern and The Journal of Chinese Medicine. However, this is not nearly enough, and non of them are fully open access and fully online.

Case Studies

Case studies have been a significant learning and teaching tool throughout the history of Chinese medicine.  Removed from a clinical narrative, Chinese medicine patterns do not easily create a picture, rather the practitioner is left with a series of check boxes that can be confusing in treatment.  Case studies can shed light on nuanced questions of diagnosis and treatment, focusing our understanding on the principle behind a treatment.

The memorization of patterns, points, and herbs only serve as the prerequisite for clinical work.  The clarity of Chinese medicine principles and an understanding of how to utilize them is the key.  In an essay or case study, the clinician can show how they came to that diagnosis and treatment.  For example, we all know that when the liver invades the spleen, it can be from the spleen weakness allowing the liver to invade, or from the liver overpowering the spleen.  The symptoms can be the very similar, the clinician must understand the principle to know where to focus.  Is it the spleen or the liver?  Which aspect is the key to make a decision?  The tongue? The complexion of the face? The fleshiness of the palm?  Digestion?  Fatigue?  The pulse?  This is where a case study can help reveal the nuances of diagnosis by pattern identification revealing the principle of treatment.

This is not to say that all great clinicians use the pattern diagnosis.  Of course, many don’t.  Whatever system, the greatest of clinicians create a central principle of treatment which is their focus for the patient.  The clinical essay and the case study will provide a platform for the many excellent clinicians in our community to share their experience and skills.

Online Open Access

The internet is having a significant impact on how people research and use information. The abundant amount of information and ease of access allows for the the easy and open exchange of ideas. Open access give all practitioners and student an opportunity to learn regardless of academic affiliation or economic means.  On the other hand, the internet also creates an environment for poor information to proliferate due to the ease of publishing.  A reputable resource must stand up to the scrutiny of the community it serves, which we believe we will do.

The internet also allows for flexibility in publishing. Ideas can be presented, compared, and reviewed as time goes on.  Rather than being etched in stone or ink, like printed material, web publishing allows for a give and take.  This flexibility matches the fluid characteristic of the medicine giving readers the ability to focus on their particular interests.

Peer Review
The editors of TCM Focus hope to develop a peer review process with transparency and integrity that is appropriate for the Chinese medicine clinical community. Peer review is a complicated and involved process, and varies from journal to journal and community to community. If you would like to get involved with developing our peer review process, please contact us.  At the moment, our editors, Joe Alban, L.Ac.and Michael Jabbour, L.Ac. will review each submitted article.

Be a Part of TCM Focus
We invite you to become a part of this project as it develops by signing up for our e-journal which will be mailed once or twice per month.  Also give us feedback by commenting on our articles as well as giving us feedback about the site in general.  And, of course, we invite you to share your clinical wisdom with us by writing articles and case studies.

We hope that the clinical case studies and essays will help inform clinicians, researchers, and decision makers about the potential usage of Chinese medicine.

Abstract:

Treating chronic prostatitis and chronic pelvic pain syndrome can be very rewarding for the Chinese medicine practitioner.  Most patients with the condition have tried many other approaches without success and fear that they will face a lifetime of pain and discomfort from this problem.  Men with this condition suffer from a constant or intermittent pain in the pelvis and perineum.  They can also have sexual dysfunction, voiding problems, depression, and anxiety.  This article focuses on Chronic Pelvic Pain Syndrome because it is the most prevalent and least understood type of chronic prostatitis. However, the Chinese medicine theory and treatment discussed here can be used for all types of chronic prostatitis.

Introduction:
Chronic Pelvic Pain Syndrome (CPPS), or Chronic Prostatitis Category III, is a painful condition that causes mild to severe pelvic pain. Men with CPPS may also experience painful, frequent, urgent, or difficult urination, as well as sexual dysfunction. These symptoms can affect all aspects of their life. In addition to the pain and discomfort, it can result in depression, lost work and educational opportunities, and trouble in relationships. Chinese medicine and acupuncture are powerful therapies for men with CPPS with a history of treating painful urination going back over 200 years.

Symptoms of CPPS

Symptoms of Chronic Pelvic Pain Syndrome can effect every aspect of the patient’s life.¹ The main symptom of Chronic Pelvic Pain Syndrome is pelvic and perineal pain. The pain can be very severe and can be located anywhere in the lower back and pelvic area including the lumbar, sacrum, lower abdomen, penis, scrotum, and rectum.

The quality of the pain can be dull, shooting, sharp, or a combination of them all. It often cycles in periods of exacerbation and relief. Other principle signs include voiding and sexual dysfunction as well as general complaints. Voiding problems include reduced urine flow, hesitancy, dribbling, and a sensation of incomplete urination. Related sexual complaints include ejaculatory pain, erectile dysfunction, and decreased libido. The general complaints include depression, fatigue, chronic body aches, and headaches.¹

Causes of Chronic Pelvic Pain Syndrome
The exact cause of Chronic Pelvic Pain Syndrome is not entirely understood. It is important to remember that while CPPS has the same symptoms as chronic bacteria prostatitis, and may develop after an infection, for the most part, there is no infection and the majority also do not have inflammation.¹ Some scientists believe that CPPS may be caused by referred pain from muscle tightness in the pelvis and back and contracture of smooth muscle such as the bladder.² Others believe that undetected inflammation is the cause. Another theory is that the syndrome is caused by intrapelvic congestion of fluids.³ Many physicians are now moving towards describing the issue as a pain syndrome, focusing more on the relief of symptoms and less on the cause of the disease. ²

Certain events of injuries can trigger the disease like the aftermath of a bacterial infection, emotional stress, physical injury, prolonged sitting, or bicycling ride.¹

The lack of clarity about the condition is troublesome to both patients and clinicians. Patients feel uneasy because they do not have a clear explanation about the cause of their problem, and clinicians cannot help solve it.

Chronic Prostatitis and CPPS in Chinese medicine
Both patients and clinicians should be happy to learn about the Chinese medicine treatment. Chinese medicine bases the diagnosis and treatment upon the manifestation of the symptoms, rather than the presence of infection or inflammation.

I find that combination treatment works best for those with CP/CPPS. Acupuncture, tui na, electric stimulation, and gua sha can address many of the physical issues associated with this condition. It is also important to consider that many men with CPPS also require education and counseling in ongoing self care.

There are some similarities between CPPS and the Qi Lin syndrome described in Su Wen (Elementary Questions) which is the first known text to mention these syndromes.⁴ Qi Lin is one of the Five Lin syndromes, or five stranguries, associated with painful urination which were classified according to the characteristics of the urine- bloody, cloudy, stony, heat, and qi. Qi lin means that the root of the disorder is caused by a problem of the qi, either qi stagnation or qi deficiency.

With CPPS, the urine most often has little change in appearance which suggests qi lin. However, some men with CPPS have a history of stones, therefore stony lin may also be a factor. The treatment for qi lin depends on differentiating of patterns and the location of the qi stagnation.

Diagnosis and Treatment Considerations

We all know the saying, “When there is stoppage, there is pain. When there is movement, there is no pain.” This means that with any pain there is some form of stagnation. The treatment must combine strategies to move the qi and blood which will stop the pain as well as correct the underlying imbalance. The most important organs to consider are the spleen, liver, kidney, and urinary bladder.

Spleen qi vacuity: The spleen is responsible for the movement of water in the body, therefore spleen disharmonies will impair urination. It is very common to have CPPS from spleen qi vacuity, particularly if frequent urination and distention in the pelvis are the most predominant symptoms. If there are spleen qi vacuity signs, the accompanying congestion in the pelvis is often due to dampness.

Other common spleen qi symptoms are bloating, loose and sticky stools, fatigue, shortness of breathe, sinus headaches, soft voice, and a scalloped tongue. Dampness can also be factor with the spleen. Spleen 9 is effective for spleen qi deficiency with dampness. SP 9 and ST 40 are a well known and effective combination for draining damp. Sp 9 can also be used in combination with Lu 5 to regulate the qi in the tai yin.⁵ If there is more deficiency, then SP 3 is a good choice. If there is tightness at Sp 8, then needling this point will help clear the stagnation in the channel. This is especially powerful when combined with UB 58.

Liver Qi stagnation: If the problem derives from referred pain due to muscle tightness, liver qi stagnation may be the problem. Other common signs include a string like pulse, rib side pain, stress, and headache. The liver channel encircles the genitalia, and is especially important to consider.

If the liver is the root problem, the combination of Lv 3 and Lv 14 is effective. Use Lv 2 if there is also heat from stagnation. GB 34 can be effective at relaxing the tight muscles. If there is pain in the genitals or scrotum, Lv 5, the luo connecting point, can be effective at opening the liver channel.

Kidney: We all know that the kidneys govern water and control most aspects of urination including both the production of urine and the opening and closing of the bladder. Weak kidney qi could be the root of the inhibited or frequent urination if it is accompanied by a weak lower back, weak knees, and a weak pulse. Also, kidneys are more likely to be the cause in older men and those who have had the symptoms for an extended period of time.

Kid 3 and Kid 7 are both effective for tonifying the kidney. Use Kid 7 if there is more of a yang vacuity. Ren 4, Du 4, and UB 23 all tonify the kidney and are local points to bring qi and blood to the area.

Urinary Bladder channel stagnation: The UB channel and organ are always involved with chronic prostatitis and it is very helpful to treat this channel. UB channel stagnation can cause painful and inhibited urination.

Palpate the channel on the leg, especially at UB 58, the luo point of that channel. If this point is tight, deep needling upwards to open the UB channel can be effective. UB 65 is also effective at clearing deep UB channel stagnation. Ren 3 is important, as it is the front mu of the UB.

Local points are also very important. Ren 3, 4, and KD 12 can be used for frequent urination. If there is yang deficiency use moxa to warm the yang. If after a few treatments, there is no improvement in frequent urination, low frequency electric stimulation on Ren and Kidney points can be effective.

Local points on the lower back and sacrum are essential to relieve pain. UB 32, 33, and Du 1 are the most important. It is important to precisely locate UB 32 and 33, and needle deep enough find de qi, using a 1.5 or 2 inch needle. Ren 1 can be helpful as well. Also, instruct the patient to massage their perineum to relieve spasm muscles.

Ashi points on the lower back and pelvis can release tight muscles throughout the hips, pelvis, and lower back. Palpate to find the tense areas.

Tui na on the lower back and pelvis will be helpful to relieve the tension. I use rolling and kneading technique of pinching the muscles to loosen the muscles. For a feeling of distention in the pelvis with inhibited urination, use gua sha UB 20-23 and pelvic area or needling with electric stimulation.

How to create an Acupuncture Treatment

Before treatment, you should get a full idea of the symptoms each patient is facing. The treatment should specifically target the root imbalance and relax the muscles of the lower back and pelvis.

Most likely there is a very deep imbalance that will take time in resolving. Start with trying to gently move the stagnated qi with only a few needles. Treat the main pattern and address the qi stagnation with the shu stream points and luo connecting of the effected channels. This will move the qi in the effected channel, but not cause muscle spasms. After one or two sessions, begin to treat the UB and Du points of the lower back and sacrum, which will help move the qi stagnation in this area of the body. Combine the treatments with rolling and pinching technique on the pelvis as well as other therapies mentioned to get the best results.

1. Nguyen CT, Shoskes DA. Evaluation of the Prostatitis Patient. In: Chronic Prostatitis/Chronic Pelvic Pain Syndrome (Current Clinical Urology). Totowa, NJ: Humama; 2008.

2. Potts JM. Physical Therapy for Chronic Prostatitis/Chronic Pelvic Pain Syndrome. In: Chronic Prostatitis/Chronic Pelvic Pain Syndrome (Current Clinical Urology). Totowa, NJ: Humama; 2008.

3. Honjo H, Kamoi K., Naya Y, et al. The Effects if Acupuncture for Chronic Pelvic Pain Syndrome with Intravenous Congestion: Preliminary Results. International Journal of Urology. 2004 Aug; 11(8): 607-612.

4. Wiseman N, Feng Y. Practical Dictionary of Chinese Medicine
. Brookline: Paradigm; 1998:583.

5. Wang JY, Robertson JD. Applied Channel Theory in Chinese Medicine
. Seattle: Eastland Press. 2008.