UNANI TIBB

ILLNESS MANAGEMENT TIB521

RENAL SYSTEM

Compiled from: BONE, MILLS, CAPASSO, LIPPINCOTT WILLIAMS & WILKINS,

BHIKHA

Introduction
The kidneys are the principle functional unit of the renal system. They remove the
breakdown products of protein metabolism, electrolytes, water and many drugs and their
metabolites. The kidneys also regulate the volume of extracellular fluid, the concentration
of extracellular electrolytes, pH of the body fluids and blood pressure. Other components
of the renal system include the bladder, the ureter and the urethra.
The main functions of the kidneys are:
Excretory the elimination of waste material (especially urea) and exogenous substances
(such as drugs and their metabolites, and environmental toxins).
Regulatory control of the bodys fluid volume and composition (low molecular weight
substances such as electrolytes and amino acids). The process of filtration by the kidney
takes place by a sequence of glomerular filtration, tubular reabsorption and tubular
secretion.
Endocrine synthesis and secretion into the bloodstream of the protein hormones renin
and erythropoietin
Metabolic metabolism of vitamin D in particular.
The functions of the kidney with respect to the temperament and structure are in line with
the inherent wisdom of needs. It also operates under the sub-faculties of attraction,
retention, alterative (metabolism) as well as repulsive (excretory/elimination).

The attractive faculty this describes the blood flow from the renal arteries and
arterioles through the glomeruli contained within the Bowmans capsule of the
nephron.

The retentive faculty this faculty retains the blood for filtration at the glomerular
membrane, and the filtrate to gather in the early proximal tubule region.

The alterative metabolic faculty this refers to the activities of the kidney,
mentioned above, which are directed at maintaining the blood pressure and
haemoglobin content of the circulating fluid.

The repulsive (or excretory) faculty this manifests in two ways. Firstly, as the
positive flow of urine down the nephron tubule to the renal calyx and pelvis, from
where it passes to the bladder via the ureters. Secondly, the flow of useful
components present in the urine back to the bloodstream (the peritubular network)
under osmotic pressure.

The main functions of the bladder are:

Storage to hold urine received from the kidney
Expulsion to expel urine from the body at a time chosen by the person.
According to Tibb, the temperament, structure and function of the bladder is
encompassed by three sub-faculties of attraction, retention and repulsion. No metabolic
or alterative changes take place in the bladder.

The three sub-faculties are:

The attractive faculty this allows waste material from the kidneys to reach the
bladder.

The retentive faculty this describes the bladders ability to accumulate and retain
urine.

The repulsive faculty this refers to the actions by which urine is expelled to the
outside via the urethra.

Temperament of the:
Kidney:_______________
Bladder:______________

Natural diuretics
Plants have been used as diuretic remedies throughout history (Pliny the elder mentions a
few plants with diuretic properties in Naturalis Historia). However, earlier indications
for the use of diuretics were quite different to what it is being used for in todays day and
age. Earlier practitioners would use diuretics in the management of conditions such as
urinary stones, nephritis, cystitis, urinary retention, incontinence, oedema associated with
dropsy, ascites, and lymphatic diseases. The diuretic effect of a purgative was supported
by observations that anthraquinone derivatives induce experimental diuresis associated
with the inhibition of ATPase in the kidney medulla.
Aquaretics and diuretics
Most plants used primarily for their effects on the urinary system are collectively referred
to as diuretics. In German practice, the concept of aquaretic has been used to describe
diuretic agents that excrete water from the body focusing mainly on potassium
concentrations with no effect on electrolyte excretion. Their effect is due to an increase in
blood flow to the kidney. Most herbal diuretics are likely to fall in this category. They are
thus not easily compared to modern allopathic diuretics that interfere with resorption at
the distal tubule of the nephron, leading to wider electrolyte elimination and thus maybe
less effective when treating hypertension and oedematous conditions.
In the case of hypertension, the main benefit of herbal aquaretics may be in replacing the
K lost through the use of modern diuretics used. High K levels relative to Na has been
shown to be a feature of herbal drugs with traditional drug activity.
Plant remedies traditionally used as diuretics
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Zea mays

Taraxacum officinae

Apium graveolens

Indications for diuretics

dysuria and oliguria linked to urinary infection or stones

heart failure (as an adjunct to cardio protect remedy)

ascitis (combined with hepatic remedies)

nocturnal enuresis and other functional disturbances of micturation

urinary stones

Contra-indications for the use of diuretics

The use of diuretics may be inappropriate and possibly even contra-indicated on the
following conditions:
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Renal failure

Diabetes

Kidneys and oedema

Although clearly active in the elimination of water from the body and the control of fluid
levels within tissue, the impact of the kidneys in oedema is not always obvious, compared
to heart failure, cirrhotic liver or lymphatic/venous insufficiency in their relevant
syndromes. Nevertheless, in all such cases prescription of conventional diuretics is
commonly used as it is widely assumed that the kidney is centrally involved in most
cases. This assumption has mixed support in scientific literature. For e.g. renal
complications of liver cirrhosis are certainly implicated in the development of ascitis.
These complications include inadequate renal prostaglandin production and the negative
effect of the kidney in raised nitric oxide production. Such complications may actually
reduce the effect of diuretics but they remain indicated in the treatment of ascites as long
as they are effective. In managing such a condition, or a condition similar, the use of
hepatics or other treatment for the liver is advisable. Although diuretics are effective
symptomatically, their isolated use in the treatment of CHF in the long term has been
challenged because of their possible excitation of the rennin-angiotensin system.

The localized oedema of lymphatic and venous insufficiency is treated with particular
remedies said to act in vessel walls. These may have incidental diuretic effects. Little is
known about the full impact of plant constituents on the kidney and although there are a
few cases where actual nephrotoxicity occurs, a general caution in using herbal
treatments is advisable when the kidneys are damaged already.
Beneficial effects of natural remedies on the kidney
By definition, the kidney in conditions such as glomerulonephritis and cystic disease,
especially where the basement membrane is involved, is vulnerable to further damage
with any new active metabolite and the practitioner need to be wary of this hence have to
proceed with caution. The use of various Chinese bitter herbs (more cooling and drying
as oppose to dryness with heat) has been shown to improve biochemical markers
associated with free radical damage in patients with chronic glomerularnephritis
compared to the control group. Protective effects of Arctostaphlos uva ursi have been
noted against nephrotoxic agents.
Beneficial effects of plant remedies on the kidney
By definition, the kidney in conditions such as glomerulonephritis and cystitis especially
where basement membrane is involved, is vulnerable to further damage hence the
practitioner need to proceed with caution

Urinary antiseptics
Plant remedies traditionally used as urinary antiseptics are as follows:
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Arctostaphlos uva ursi

Barosma betulina

Berberis vulgaris

Indications for urinary antiseptics:

UTI or stones

Prostatitis

Cystitis

Contra-indications:
The use of diuretics may be inappropriate and possibly even contra-indicated on the
following conditions:
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kidney disease

renal failure

pregnancy

The most common problems with the renal system arises from:
a) infection
b) renal obstruction
c) renal failure
d) bladder infection
A prompt diagnosis and appropriate therapy are fundamental to prevent or eliminate
glomerulonephritis, pyelonephritis, hydronephrosis (accumulationof urine within the
renal pelvis), renal failure and bladder infection.

Unani Tibb for urinary conditions

The illnesses developing in the urinary tract are associated with the function of the kidney
and the bladder. As the temperament of the kidney is Hot & Moist, and that of the
bladder Cold & Dry, it is expected that most of the illnesses would be associated with
changes to the ideal temperament of these two organs.

Common (general) warning signs of urinary system diseases are:

1. Symptoms which localized in the urinary tract.
2. Raised blood pressure.
3. Evidence of blood or protein in the urine.
4. An elevated serum urea.
5. An elevated blood creatinine.
6. Frequent urination, especially at night (nocturia).
7. Difficult or painful urination (dysuria).
8. Puffiness around eyes, swelling of hands and feet, especially in children.

Conditions
Cystitis (Bladder infection)

Bladder calculus

Glomerular nephritis

Diabetes insipidus

Dysuria

Oliguria

Enuresis (Bedwetting)

Haematuria

Polyuria

Renal Calculi (kidney stones)

Incontinence (bladder
weakness)

Urethritis

Nephritis

A) Diabetes insipidus

(Imbalanced quality:________________)

Diabetes insipidus is a rare disorder of water metabolism. It is caused by a lack of, or

non-response to the anti-diuretic hormone vasopressin. Vasopressin is made by the cells
of the hypothalamus (located in the brain) and is stored and secreted by another part of
the brain called the posterior pituitary gland. The antidiuretic hormone is then released
into the bloodstream where it causes tubules within the kidney to reabsorb water. Water
that cannot be reabsorbed is passed out of the body in the form of urine. Decreased
secretion of vasopressin causes less water to be reabsorbed and more urine to be formed.
When vasopressin is present at normal levels, more water is reabsorbed and less urine is
formed.
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Management
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B) Nephrolithiasis - Renal calculi

(Imbalanced quality:________________)

Most calculi originate within the kidney and proceed distally, creating various degrees of
urinary obstruction as they become lodged in narrow areas, including the ureteropelvic
junction, pelvic brim, and ureterovesical junction. Location and quality of pain are related
to position of the stone within the urinary tract. Severity of pain is related to the degree of
obstruction, presence of ureteral spasm, and presence of any associated infection. This
pain has been likened to the discomfort of childbirth. Most calculi arise in the kidney
when urine becomes supersaturated with a salt that is capable of forming solid crystals.
Symptoms arise as these calculi become impacted within the ureter as they pass toward
the urinary bladder. Approximately 80-85% of stones pass spontaneously. Approximately
20% of patients require hospital admission because of unrelenting pain, inability to retain
fluids, proximal urinary tract infection (UTI), or inability to pass the stone. A ureteral
stone associated with obstruction and upper UTI is a true urologic emergency.
Complications include perinephric abscess, urosepsis, and death. Refer immediately.
Case study:
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Management
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C) Vesicular lithiasis (Bladder calculi)

(Imbalanced
quality:________________)
Vesical calculi refer to the presence of stones or calcified materials in the bladder. These
stones are usually associated with urinary stasis, but they can form in healthy individuals
without evidence of anatomic defects, strictures, infections, or foreign bodies. The
presence of upper urinary tract calculi is not necessarily a predisposition to the formation
of bladder stones. The most common type of vesical stone in adults is composed of uric
acid (>50%). Less frequently, bladder calculi are composed of calcium oxalate, calcium
phosphate, ammonium urate, cysteine, or magnesium ammonium phosphate (when
associated with infection). Interestingly, patients with uric acid bladder calculi rarely ever
have a documented history of gout or hyperuricemia. Vesical calculi may be single or
multiple, especially in the presence of bladder diverticula. Vesical calculi can be small or
large enough to occupy the entire bladder. Their physical features range from soft to
extremely hard and from having smooth-faceted surfaces to jagged spiculated surfaces,
the latter termed "jack" stones based on their resemblance to the metal objects in the
children's game Jacks. In general, most vesical calculi are mobile within the bladder,
although some stones are fixed when they form on a suture, on the intravesical portion of
a papillary tumor, or on retained stents.
Case study:
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Management
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D) Cystitis

(Imbalanced quality:________________)

Interstitial cystitis (IC) is a clinical syndrome characterized by daytime and night time
urinary frequency, urgency, and pelvic pain. According to western medicine the
pathophysiology of interstitial cystitis is poorly understood. Various etiologies have been
proposed, none of which adequately explains the variable presentations, clinical courses,
or responses to therapies. However, according to Tibb, the aetiology of this condition is
easily explained as it is due to excessive heat with almost equal amounts of moisture and
dryness in the system. A cystoscopy reveals a diffusely reddened appearance to the
bladder surface epithelium associated with one or more ulcerative patches surrounded by
mucosal congestion (ie, Hunner ulcer) on the dome or lateral walls of the bladder. These
ulcers may become apparent only after overdistension because discreet areas of mucosal
scarring rupture during the procedure. Overdistension of interstitial cystitis results in
fissures and cracks that bleed in the bladder epithelium.

Case study:
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Management
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E) Nephritis

(Imbalanced quality:________________)

Tubulo-interstitial nephritis may be acute or chronic, and it often results in kidney failure.
It may be caused by various diseases, drugs, toxins, or radiation that damages the
kidneys. Damage to the tubules results in changes in the concentrations of electrolytes in
the blood or in problems with the kidney's ability to concentrate urine. There are two
parts of the kidney tubules, the proximal and the distal. When the proximal tubule is
damaged, the normal re-absorption into the blood of sodium, potassium, bicarbonate, uric
acid, and phosphate may be altered, resulting in low levels in the blood of these
substances. Injuries to the distal tubule are usually associated with a loss of urineconcentrating ability and an increase in daily urine volume

Case study:
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Management
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F) Glomerular nephritis

(Imbalanced quality:________________)

Acute glomerulonephritis refers to a specific set of renal diseases in which an

immunologic mechanism triggers inflammation and proliferation of glomerular tissue
that can result in damage to the basement membrane or capillary endothelium.
Hippocrates originally described the manifestation of back pain and hematuria, which
lead to oliguria or anuria. With the development of the microscope, Langhans was later
able to describe these pathophysiologic glomerular changes. Glomerular lesions in acute
glomerulonephritis are the result of glomerular deposition formation of immune
complexes. On gross appearance, the kidneys may be enlarged up to 50%.
Histopathologic changes include swelling of the glomerular tufts and infiltration with
polymorphonucleocyte. Most original research focuses on the poststreptococcal patient.
Acute glomerulonephritis is defined as the sudden onset of hematuria, proteinuria, and
red blood cell casts. This clinical picture is often accompanied by hypertension, edema,
and impaired renal function. Acute glomerulonephritis can be due to a primary renal or
systemic disease.

Case study:
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(Class discussion)
Management
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G) Urethritis

(Imbalanced quality:________________)

Urethritis is defined as infection-induced inflammation of the urethra. Although

various clinical conditions may result in irritation of the urethra, the term urethritis is
typically reserved to describe urethral inflammation caused by a sexually transmitted
disease (STD). Urethritis is normally categorized into one of two forms, based on
etiology: gonococcal urethritis (GU) Neisseria gonorrhoeae and nongonococcal
urethritis (NGU) Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma
hominis, Mycoplasma genitalium, or Trichomonas vaginalis. Approximately 10%40% of women with urethritis eventually develop pelvic inflammatory disease (PID),
which may subsequently cause infertility and ectopic pregnancy secondary to
postinflammatory scar formation in the fallopian tubes. PID can occur even in women
with asymptomatic infections.

Case study:
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Management
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H) Enuresis

(Imbalanced quality:________________)

The word enuresis is derived from a Greek word that means "to make water." In North
America, the term is used to refer to wetting by night or day. Enuresis can be divided into
primary enuresis (PE) and secondary enuresis (SE). A child who has experienced a
minimum 6-month period of continence before the onset of the bedwetting is considered
to have SE.
Psychological and social impact: In PE, psychological problems are almost always the
result and only rarely the cause. By contrast, psychological problems are a possible cause
in SE. The emotional impact of enuresis on a child and family can be considerable.
Children with enuresis are commonly punished and are at significant risk of emotional
and physical abuse. Numerous studies report feelings of embarrassment and anxiety in
children with enuresis; loss of self-esteem; and effects on self-perception, interpersonal
relationships, quality of life, and school performance. 1 A significant negative impact on
self-esteem is reported even in children with enuretic episodes as infrequent as once per
month.

Case study:
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Management
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I) Oliguria

(Imbalanced quality:________________)

Oliguria is defined as a urine output that is less than 1 mL/kg/h in infants, less than 0.5
mL/kg/h in children, and less than 400 mL/d in adults. It is one of the clinical hallmarks
of renal failure and has been used as a criterion for diagnosing and staging acute renal
failure. At onset, oliguria is frequently acute. It is often the earliest sign of impaired renal
function and poses a diagnostic and management challenge to the clinician. All cases of
acute renal failure are not characterized by oliguria. For example, subjects with acute
renal failure due to nephrotoxins, interstitial nephritis, or neonatal asphyxia are typically
nonoliguric. In addition, the degree of oliguria depends on hydration and concomitant use
of

diuretics.

In most clinical situations, acute oliguria is reversible and does not result in intrinsic renal
failure. However, identification and timely treatment of reversible causes is crucial
because the therapeutic window may be small.

Case study:
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Management
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J) Polyuria

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Polyuria is urine output of > 3 L/day; it must be distinguished from urinary frequency,
which is the need to urinate many times during the day or night but in normal or lessthan-normal volumes. Either problem can include nocturia.
Pathophysiology: Water homeostasis is controlled by a complex balance of water intake
(itself a matter of complex regulation), renal perfusion, glomerular filtration and tubular
reabsorption of solutes, and reabsorption of water from the renal collecting ducts.
When water intake increases, blood volume increases and thus renal perfusion and GFR
increase, resulting in increased urine volume. However, the increased water intake lowers
blood osmolality, decreasing release of ADH (also referred to as arginine vasopressin)
from the hypothalamicpituitary system. Because ADH promotes water reabsorption in
the renal collecting ducts, decreased levels of ADH increase urine volume, allowing body
water to return to normal.

Case study:
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Management
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K) Dysuria

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Dysuria is painful or uncomfortable urination, typically a sharp, burning sensation. Some

disorders cause a painful ache over the bladder or perineum. Dysuria is an extremely
common symptom in women, but it can affect men and can occur at any age.
Pathophysiology: Dysuria results from irritation of the bladder trigone or urethra.
Inflammation or stricture of the urethra causes difficulty in starting urination and burning
on urination; irritation of the trigone causes bladder contraction, leading to frequent and
painful urination. Dysuria most frequently results from an infection in the lower urinary
tract, but it could also be associated with an upper UTI. Impaired renal concentrating
ability is the main reason for frequent urination in upper UTIs.

Case study:
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Management
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Medication:
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Additional therapies:
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L) Hematuria

(Imbalanced quality:________________)

Generally, hematuria is defined as the presence of 5 or more RBCs per high-power field in
3 of 3 consecutive centrifuged specimens obtained at least 1 week apart. In the office
setting, a positive reaction on the urine dipstick test is usually the first indication of the
presence of hematuria. Hematuria can be gross (i.e., the urine is overtly bloody, smoky, or
tea coloured) or microscopic. It may be symptomatic or asymptomatic, transient or
persistent, and either isolated or associated with proteinuria and other urinary
abnormalities. The aetiology and pathophysiology of hematuria vary. For instance,
hematuria of glomerular origin may be the result of a structural disruption in the integrity
of glomerular basement membrane caused by inflammatory or immunologic processes.
Chemicals may cause toxic disruptions of the renal tubules, whereas calculi may cause
mechanical erosion of mucosal surfaces in the genitourinary tract, resulting in hematuria.
Case study:
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(Class discussion)
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Management
Governing factors:
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Medication:
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Additional therapies:
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M) Incontinence

(Imbalanced quality:________________)

Urinary incontinence (UI) is defined as "a condition in which involuntary loss of urine is
a social or hygienic problem and is objectively demonstrable. Micturition requires
coordination of several physiological processes. Somatic and autonomic nerves carry
bladder volume input to the spinal cord and motor output innervating the detrusor,
sphincter, and bladder musculature is adjusted accordingly. The cerebral cortex exerts a
predominantly inhibitory influence, whereas the brainstem facilitates urination by
coordinating urethral sphincter relaxation and detrusor muscle contraction. As the bladder
fills, sympathetic tone contributes to closure of the bladder neck and relaxation of the
dome of the bladder and inhibits parasympathetic tone. At the same time, somatic
innervation maintains tone in the pelvic floor musculature as well as the striated
periurethral

muscles.

When urination occurs, sympathetic and somatic tones in the bladder and periurethral
muscles diminish, resulting in decreased urethral resistance. Cholinergic parasympathetic
tone increases resulting in bladder contraction. Urine flow results when bladder pressure
exceeds urethral resistance. Normal bladder capacity is 300-500 mL, and the first urge to
void

generally

occurs

between

bladder

volumes

of

150

and

300

mL.

Incontinence occurs when micturition physiology, functional toileting ability, or both

have been disrupted.The underlying pathology varies among the different types of
incontinence:
Stress incontinence
Urge incontinence
Mixed incontinence
Overflow incontinence
Functional incontinence
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Case study:
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(Class discussion)
Management
Governing factors:
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Medication:
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Additional therapies:

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35