Case 4: Mr. Ji, male, 55 years old

Case 4: Mr. Ji, male, 55 years old

Initial Consultation: March 12, 2019
Chief Complaint: Generalized edema and dizziness with nausea for one month. Past medical history: more than ten years of chronic nephritis. Low back soreness and fatigue, insomnia with frequent dreams, sleeping only about two hours per night, palpitations and forgetfulness, feeling cold and having cold limbs, dry stools, purple-dark tongue, white greasy coating, ecchymoses along the edges, and a deep, fine pulse.
Examination: Urinary protein (+++), urinary occult blood (+), urea nitrogen 19.8 mmol/L, serum creatinine 420 µmol/L, triglycerides 3.6 mmol/L, total protein 50 g/L, albumin 28 g/L, globulin 22 g/L, blood pressure 140/90 mmHg, obvious hypoproteinemia.
Western Medical Diagnosis: Chronic nephritis, renal failure.
Traditional Chinese Medicine Syndrome Differentiation: Kidney yang deficiency, heart and brain malnutrition, restlessness of the mind, blood stasis obstructing the collaterals.
Treatment Principle: Tonify kidney yang, nourish heart and calm the spirit, activate blood circulation and resolve stasis.
Prescription: Zhenwu Tang, Compound Sour Jujube Seed Decoction, Renal Failure Formula with modifications.
Ingredients: Acorus calamus 15 g, Night-blooming Jasmine 20 g, Salvia miltiorrhiza 20 g, Amber powder 3 g (added later), Aconite 6 g (decocted first), White peony root 10 g, Dried ginger 6 g, Poria cocos 10 g, Atractylodes macrocephala 10 g, Sour Jujube seed 10 g, Platycladus orientalis seed 10 g, Ligusticum chuanxiong 10 g, Anemarrhena asphodeloides 20 g, Albizia bark 30 g, Polygala tenuifolia 10 g, Rheum palmatum 10 g (added later), Astragalus 30 g, Plantago seeds 15 g, Motherwort 30 g, Honeysuckle 15 g, White Snake Tongue Herb 15 g, Goji berries 15 g, Mulberry 15 g, Cornus officinalis 10 g, Panax notoginseng 3 g (added later), Leech 10 g (added later). Total of 14 doses, one dose every other day.
In addition, 100 g of raw Rheum palmatum and 300 g of oyster shell powder were ground into powder, and 10 g was taken three times daily to adsorb urea nitrogen in the intestines and improve renal function.
Second Consultation: After one month of medication, edema and dizziness eased, sleep improved, with five to six hours of sleep per night, urinary protein (+), urinary occult blood (-), blood pressure 130/80 mmHg, tongue red with thin white coating and ecchymoses along the edges, pulse deep and fine. The syndrome was attributed to kidney deficiency and blood stasis, so Jin Gui Shen Qi Tang combined with Yi Shen Tang with modifications was prescribed.
Prescription: Cinnamon 10 g, Aconite 6 g (decocted first), Rehmannia glutinosa 10 g, Cornus officinalis 6 g, Atractylodes macrocephala 10 g, Poria cocos 10 g, Cortex Moutan 6 g, Plantago seeds 10 g, Peach kernel 10 g, Safflower 6 g, Angelica sinensis 10 g, White peony root 10 g, Ligusticum chuanxiong 10 g, Su stem 20 g, Cicada slough 6 g, Motherwort 15 g, Honeysuckle 15 g, Albizia bark 15 g, Night-blooming Jasmine 15 g, Acorus calamus 10 g, Panax notoginseng 3 g (added later), Leech 10 g (added later). Continue taking the large quantities of Rheum palmatum and oyster shell powder. Total of 30 doses.
Third Consultation: The patient’s symptoms improved significantly: urinary protein (-), urinary occult blood (-), urea nitrogen 8.8 mmol/L, serum creatinine 80 µmol/L, triglycerides 1.6 mmol/L, total protein 60 g/L, albumin 30 g/L, globulin 20 g/L—all indicators returned to normal ranges. The patient is still taking the medication.