I. Introduction

Chronic renal failure (CRF) is a common renal disorder in both dogs and cats. There is little treatment available from a Western perspective, other than fluid therapy and a protein-restricted diet, for the end stages of CRF. Other recommended dietary changes include reducing quantities of phosphorus and sodium and increasing caloric density, potassium, dietary fiber, B-vitamin content, and magnesium.^1,2 Recent studies have shown that antioxidants and Ω-3 polyunsaturated fatty acids (PUFAs) may benefit patients with renal failure. Antioxidants relax smooth muscle and increase glomerular filtration rate.⁸ Fish oil reduces plasma lipids and intraglomerular pressure.⁹ Ω-3 fatty acids heal glomerular and tubulointerstitial lesions, which may offer some protection of glomerular function, thereby minimizing renal disease progression.¹⁰ Other mechanisms of Ω-3 fatty acids include anti-inflammatory, anti-coagulant, and antioxidant effects, as well as reducing intrarenal calcification.^3,4

Traditional Chinese Veterinary Medicine (TCVM) has more to offer patients with CRF, as it has been used in animals for thousands of years in China.⁵ Clinical anecdotal evidence indicates acupuncture and Chinese herbals may greatly benefit patients with renal failure and slow the disease progression.^6,7 Acupuncture has shown to significantly improve the renal functions on the recovery from ethylene glycol-induced, acute renal injury in dogs.¹¹ These improvements in renal functions are likely due to acupuncture’s neuromodulatory influence on autonomic tone.¹² Many Chinese herbs or herbal mixture (formula) have been shown to lower the serum creatinine level, increase inulin clearance, decrease urinary protein excretion, and attenuate lipid derangements in human or animal models with CRF.¹³

II. General TCVM Treatment

In the theory of TCVM, the notion of the ‘Kidney’ is not the same as that of the kidney in Western medical science. Kidney in the TCVM perspective is ‘the place where the true Yin and true Yang hibernate; it is the base of hiding and the place for storing the refined energy and essence. Its quintessence appears on the hair, and its function is to enrich the marrow of bone, and it associates with water.¹⁴ Thus, abnormalities of ‘Kidney’ are believed to cause multiple disturbances of the body.¹⁴ Several clinical signs related to CRF were recorded, such as edema, ‘guan-ge’ (anuria with vomiting), ‘ni-du’ (stranguria), and ‘long-bi’.¹⁴

The general treatment principle for CRF is to:

• Drain Dampness to regulate immune system and promote urination
• Activate and nourish Blood
• Resolve Stasis
• Replenish vital energy
• Coordinate Yin and Yang

Common acupoints for seizures and its functions:

• Strengthen Kidney Qi: BL-23/52, BL-26, KID-3, Shen-shu
• Warm Kidney Yang: GV-3/4, BL-24, CV-6, Bai-hui, Shen-shu/peng/jiao
• Nourish Yin: BL-23, KID-1/3/7, SP-6/9, Shen-shu
• Benefit urination: BL-22/28, SP-9/15, GB-25, ST-28, CV-9

Additional acupoints for clinical signs:

• Poor appetite: Shan-gen, Jian-wei, BL-20/21, ST-36
• Poor digestion: BL-20/21, ST-25/36
• Nausea/vomiting: PC-6, BL-20/21, ST-36, GB-34
• Diarrhea: ST-36, SP-6, BL-25, GV-1
• Edema: GV-4, SP-6
• Stranguria: CV-3, BL-39
• Heat: LI-4, LI-11, GV-14, Er-jian, Wei-jian
• Abdominal pain: SP-6
• Restlessness/abnormal behavior: PC-6, HT-7
• Panting/coughing: CV-17, BL-43, BL-13
• Hearing loss: SI-9
• Anemia: BL-17, BL-20, BL-23, SP-10
• Hypertensive: PC-6, LI-4, KID-1, LIV-3, GB-20, GB-34
• Itchy skin: LI-11, St-36, GB-20, SP-10

Methods of stimulation:

• Dry needle for 20–30 minutes
• Electroacupuncture, 20 Hz for 10–15 minutes, followed by 80–120 Hz for 10–15 minutes
• Aquapuncture, vitamin B₁₂ injected into 5–10 acupoints, 0.1–0.3 cc per acupoint
• Moxibustion at GV-4, BL-23/24, CV-6, KID-3, SP6 for patient with Kidney Yang deficiency or edema
• Acupressure or laser acupuncture

Tui-na massage:

• Mo-fa (touching Skin and Muscle) or Ca-fa (rubbing) along the back-shu Bladder meridian (BL-28 to BL-11) and along the Conception Vessel meridian (CV-8 to CV-2) for 3–5 minutes
• Rou-Fa (Rotary-kneading) along the back-shu Bladder meridian (BL-28 to BL-11) from caudal to rostral and along the Governing Vessel meridian (GV-2 to GV-14) back and forth 12 times
• Rou-fa along the Conception Vessel meridian (CV-8 to CV-2) back and forth 12 times
• Clockwise thumb Rou-fa to stimulate GV-4, GV-14, and GV-20 for 1–3 minutes
• Ca-fa and Rou-fa along the medial thigh over the 3 Yin channels (Kidney, Spleen, and Liver) of the hind limbs, following the flow of the meridians (from foot to upper limb) for 3–5 minutes
• Clockwise thumb Rou-fa to stimulate KID-3 and KID-7 for 1–3 minutes
• Single-finger Ji-dian-fa (dotting) to stimulate ST-36 for 1–3 minutes

Ten common Chinese herbs for CRF:

• Huang-qi (Astragalus membranaceus or Astragalus mongholicus), Chuan-Xiong (Ligusticum chuanxiong), Dang-gui (Angelica sinensis), Da-huang (Rheum palmatum), Dan-shen (Radix salvia miltiorrhiza), Dong-cong-xia-xao (Cordyceps sinensis), Di-huang (Salvia miltiorrhiza), Fang-ji (Stephania tetrandra), Fu-ling (Poria cocos), Lei-gong-teng (Tripterygium wilfordii)

There are hundreds of Chinese herbs used to treat chronic kidney diseases. Many of them have been shown to improve renal function in patients with CRF in a number of studies. Their mechanisms of action are mainly related to antioxidation, anti-fibrosis, and improvement of metabolic disturbance in CRF. Unfortunately, the effective components or chemical compounds in most of these herbs remain unknown due to the difficulty of pharmacodynamic studies of herbs and the isolation of active ingredients from herbs or herbal mixtures.

Huang-qi (Astragalus membranaceus or Astragalus mongholicus) has multiple beneficial effects on stimulation of the immune system, promotion of diuretic activity, antioxidation, anti-inflammation, and renoprotection. It decreases glomerular hyperperfusion and proteinuria, and improves the plasma levels of total cholesterol and albumin.

Da-huang (Rheum palmatum L.) plants have been studied extensively in China.¹⁵ It was found that rhubarb lowers the serum creatinine level, increases inulin clearance, decreases urinary protein excretion, and attenuates lipid derangements.¹⁵ Some studies reported that rhubarb not only has a renoprotective effect by itself, but it also may have an additive beneficial effect with ACE inhibitors.¹⁵ In a systemic review of 18 randomized or quasi-randomized trials from 15 Chinese journals, rhubarb showed a positive effect on relieving uremic symptoms, lowering serum creatinine, improving hemoglobin levels, and adjusting disturbance of lipid metabolism in 1,322 human patients with CRF.¹⁶

Among other kinds of Chinese herbs used to treat CRF, Dan-shen (Radix salvia miltiorrhiza) relaxes vessels by enhancing microvascular protein synthesis of endothelial nitric oxide synthase, leading to an increase in nitric oxide production.¹⁷ Danshen, in combination with seven other herbs including Chinese rhubarb, confers nephroprotection in chemical-induced acute and chronic renal failure in rats.¹⁸ Animal studies have shown that Dong-cong-xia-xao (Cordyceps sinensis) delays progression of worsening kidney function in 5 of 6 nephrectomized rats, through the inhibition of glomerular hypertrophy, reduction of proteinuria, and reversal of metabolic abnormalities of protein and the lipid profile.¹⁹ Fang-ji (Stephania tetrandra) decreases the accumulation of extracellular matrix and reduces glomerulosclerosis in Adriamycin-induced nephrotic rats.²⁰ Lei-gong-teng (Tripterygium wilfordii) has been known for protein excretion in many types of CRF.²¹

III. Pattern Differentiation and Treatment

Kidney Qi Deficiency

• Signs: Dysuria, polyuria, stranguria, lower back pain, hindlimb weakness, exercise intolerance, tires easily, urinary incontinence, uremia, prefers warm area. Tongue is pale and wet. Pulses are deep and weak (right pulse is weaker).
• Acupuncture treatment: Strengthen Kidney Qi (BL-23/52, BL-26, KID-3, Shen-shu); benefit urination (BL-22/28, SP-9/15, GB-25, ST-28, CV-9); add additional points above to manage clinical signs, if needed.
• Herbal formula:
• Suo Quan Wan, 0.5 g per 1,020 lb bodyweight BID–TID, to treat renal failure with mild urinary incontinence
• Jin Suo Gu Jing, 0.5 g per 1,020 lb bodyweight BID–TID, to treat renal failure with chronic urinary incontinence and weakness

Kidney Yang Deficiency

• Signs: Often older animals or end-stage CRF; low body temperature; cold ears, back and extremities; aversion to cold; warm-seeking behavior; subdued manner; lower back or lumbar region soreness; hearing loss; copious/long clear urine; urinary incontinence; general debility/weakness; morning diarrhea; edema in limbs or ventral abdomen. Tongue is pale, wet, and swollen with teeth marks. Pulses are weak, deep, and slow (right pulse is weaker).
• Acupuncture treatment: Warm Kidney Yang (GV-3/4, BL-24, CV-6, Bai-hui, Shen-shu/peng/jiao); benefit urination (BL-22/28, SP-9/15, GB-25, ST-28, CV-9); add additional points above to manage clinical signs if needed; use less acupoints (typically 5–10 needles in total) for debilitated patients.
• Herbal formula:
• Jin Gui Shen Qi Wan or Rehmannia 11, 0.5 g per 1,020 lb bodyweight BID–TID, to tonify Kidney Qi and Yang; nourish Yin, Blood and Jing; drain Damp; and strengthen the Spleen. Jin Gui Shen Qi Wan is slightly warmer than Rehmannia 11.
• Zhen Wu Tang, 0.5 g per 1,020 lb bodyweight BID–TID, if edema is noted. It tonifies Kidney Yang, drains Damp, and promotes urination.
• Caution should be taken when using either formula in cats or geriatrics, as they both contain Fu Zi (Aconite).

Kidney Yin Deficiency

• Signs: Dysuria, stranguria, polyuria, easily dehydrated, dry coat with dandruff, warm to the touch, cool-seeking behavior, excessive panting, generalized erythema, restlessness or abnormal behavior at night, signs often worse at night. Tongue is red and dry with cracks and little to no coating. Pulses are weak, deep, thready, and fast (left pulse is weaker).
• Acupuncture treatment: Nourish Yin (BL-23, KID-1/3/7, SP-6/9, Shen-shu); benefit urination (BL-22/28, SP-9/15, GB-25, ST-28, CV-9); clear Heat is needed (LI-4, LI-11, GV-14, Er-jian, Wei-jian); add additional points above to manage clinical signs, if needed.
• Herbal formula:
• Liu Wei Di Huang Wan, 0.5 g per 1,020 lb bodyweight BID–TID, to nourish Yin and Jing, tonify Kidney Qi, and drain excess Damp.
• Zhi Bai Di Huang, 0.5 g per 1,020 lb bodyweight BID–TID, to nourish Yin and Jing, tonify Kidney Qi, drain excess Damp, and clear Heat; it is used when apparent Heat signs are noted.
• In CRF patients with both Kidney Qi and Yin deficiency, use Jin Gui Shen Qi Wan or You Gui Wan in the morning to tonify Kidney Qi-Yang; in the afternoon, use Liu Wei Di Huang Wan or Zuo Gui Wan to nourish Yin and Jing. The dosage is 0.5 g per 1,020 lb bodyweight of each formula.

Kidney Jing Deficiency

• Signs: Renal failure at a young age, other congenital problems from an early age, congenital defects, poor neonatal growth and development, developmental bone diseases, premature aging, poor dentition, failure to thrive, often also show signs of Kidney Yin or Yang deficiency. Tongue is pale or red but can be normal. Pulses are usually weak but can be normal.
• Acupuncture treatment: Benefit urination (BL-22/28, SP-9/15, GB-25, ST-28, CV-9); for Qi deficiency, use BL-23/52, BL-26, KID-3, Shen-shu; for Yang deficiency, use GV-3/4, BL-24, CV-6, Bai-hui, Shen-shu/peng/jiao; for Yin deficiency, use BL-23, KID-1/3/7, SP-6/9, Shen-shu; add additional points above to manage clinical signs, if needed.
• Herbal formula: Sheng Jing San or Epimedium powder, 0.5 g per 1,020 lb bodyweight BID–TID, to tonify Qi, nourish Kidney Yin and Yang, Jing and Blood. Because this formula is warm, if the patient shows more signs of Yin deficiency with Heat, treat it as a case of Kidney Yin deficiency initially.

IV. Summary

There is little treatment available for chronic renal failure from a Western perspective. In contrast, Traditional Chinese Veterinary Medicine has treatment options for patients with CRF, which may minimize the progression of disease and may help maintain quality of life. The combination of herbal medicine, acupuncture, and dietary management—in addition to Western treatments—can be a very effective therapeutic approach to treat chronic renal failure in small animals.

References

1.  Polzin DJ, Osborne CA, Adams LD, O’Brien TD. Dietary management of canine and feline chronic renal failure. Vet Clin North Am Small Anim Pract. 1989;19(3):539–560.

2.  Finco DR, Brown SA, Crowell WA, Groves CA, Duncan JR, Barsanti JA. Effects of phosphorus/calcium-restricted and phosphorus/calcium-replete 32% protein diets in dogs with chronic renal failure. Am J Vet Res. 1992;53(1):157–163.

3.  Brown SA, Brown CA, Crowell WA, et al. Beneficial effects of chronic administration of dietary ω-3 polyunsaturated fatty acids in dogs with renal insufficiency. J Clin Lab Med. 1998;131:447–455.

4.  Grauer GR, Greco DS, Behrend EN, et al. Effects of dietary n-3 fatty acid supplementation versus thromboxane synthetase inhibition on gentamicin-induced nephrotoxicosis in healthy male dogs. Am J Vet Res. 1996;57(6):948–956.

5.  Zhongjie Liu, Jianqin Xu, eds. Traditional Chinese Veterinary Medicine (3rd ed., in Chinese). Beijing: China Agricultural Press; 2005.

6.  Xie S, Yao Y, Zhu J. Evaluate curative effect of chronic renal failure by methods of Bushen Jianpi Huoxue Paidu Zhongguo Zhong Yao Za Zhi. 2009;34(16):2097–2100.

7.  Liu J, Song KH, You MJ, Son DS, Cho SW, Kim DH. The effect of oculo-acupuncture on recovery from ethylene glycol-induced acute renal injury in dogs. Am J Chin Med. 2007;35(2):241–250.

8.  Pugliese A, Gruppillo A, Di Pietro S. Clinical nutrition in gerontology: chronic renal disorders of the dog and cat. Vet Res Comm. 2005;29(Suppl. 2):57–63.

9.  Pugliese A, Gruppillo A, Di Pietro S. Clinical nutrition in gerontology: chronic renal disorders of the dog and cat. Vet Res Comm. 2005;29(Suppl. 2):57–63.

10.  Brown SA, Brown CA, Crowell WA, et al. Beneficial effects of chronic administration of dietary ω-3 polyunsaturated fatty acids in dogs with renal insufficiency. J Clin Lab Med. 1998;131:447–455.

11.  Liu J, Song K-H, You M-J, et al. The effect of oculo-acupuncture on recovery from ethylene glycol-induced acute renal injury in dogs. Am J Chin Med. 2007;35(2):241–250.

12.  Chen HC. Effects of moxibusting Point Kuan-Yuan on cardiovascular and renal responses to histamine-induced shock. Am J Chin Med. 1987;15(1–2):77–82.

13.  Xiaomei Li, Haiyan Wang. Chinese herbal medicine in the treatment of chronic kidney disease. Adv Chronic Kidney Dis. 2005;12(3):276–281.

14.  Xie Zh-F. The knowledge and treatment of nephritis by traditional Chinese medicine. In: Wang H, ed. Nephrology. 2nd ed. Beijing, China: People’s Health Press; 1995:1675–1688.

15.  Li L. End-stage renal disease in China. Kidney Int. 1996;49:287–301.

16.  Li Z, Qng P, Guo L, et al. Systematic review of rhubarb for chronic renal failure [in Chinese]. Chin Evid Based Med. 2004;4:468–473.

17.  Kim DD, Sanchez FA, Duran RG, et al. Endothelial nitric oxide synthase is a molecular vascular target for the Chinese herb Danshen in hypertension. Am J Physiol Heart Circ Physiol. 2007;292(5):H2131–7.

18.  Ngai HHY, Sit W-H, Wan JMF. The nephroprotective effects of the herbal medicine preparation, WH30+, on the chemical-induced acute and chronic renal failure in rats. Am J Chin Med. 2005;33(3):491–500.

19.  Cheng Q, Yu L, Shi S, et al. Effect of Cordyceps sinensis on renal histological changes in 5/6 nephrectomized rat [in Chinese]. Chin J Nephrol. 1994;10:30–34.

20.  Dong X, An Z, Yang H, et al. Effect of tetrandrine on extracellular matrix in nephrotic rats [in Chinese]. Chin J Nephrol. 2000;16:115–117.

21.  Wang X, Yu R, Guo J, et al. Effect of extract from overground part of Tripterygium wilfordii Hook F on masugi nephritis in rabbits. China J Chin Material Med. 2000;25:231–233.