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The scope of homoeopathy in improving the quality of life in patients with end-stage renal disease: A case series
*Corresponding author: Dr. Mehvish Haris Dandoti, Department of Homoeopathic Philosophy and Organon, Dr. M.L. Dhawale Memorial Homoeopathic Institute, Palghar, Maharashtra, India. mehvish0027@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Dandoti MH, Kapse AR. The scope of homoeopathy in improving the quality of life in patients with end-stage renal disease: A case series. J Intgr Stand Homoeopathy 2021;4(1):4-11.
Abstract
Objectives:
Lifestyle disorders such as diabetes mellitus, hypertension and cardiovascular diseases eventually affect the kidneys, often causing renal failure. The current gold standard methods for managing renal failure are renal replacement therapy and haemodialysis. Unfortunately, dialysis deteriorates the patient’s quality of life (QOL). Homoeopaths rarely treat cases with such advanced irreversible pathology; the scope of homoeopathy in such cases is, therefore, unclear. We observed the effect of homoeopathy as an adjuvant on the QOL in patients with end-stage renal disease (ESRD). The QOL was assessed using the Marathi version of the Kidney Disease QOL Short Form 1.3 (KDQOL SF version 1.3).
Materials and Methods:
Three Indian patients with ESRD (two men and one woman, individualized ages 38, 50 and 54 years) consented to have their data published. The cases were managed with constitutional homoeopathic remedies in the 50 millesimal (LM) potency as an adjuvant to their current allopathic medications and were observed for 6 months. They were assessed with the Marathi version of the KDQOL SF 1.3 before and after homoeopathic management along with regular haemodialysis.
Results:
The patients showed significant improvements in the QOL, especially in the areas of sleep, pain, symptoms and problems, cognitive functioning, emotional well-being and social functioning, as assessed based on the increase in scores in their respective domains.
Conclusion:
The results of the observations are promising and in concurrence with homoeopathic philosophy; the benefits of constitutional medicines were seen. All three patients showed an improvement in their QOL. However, studies with larger sample size and randomised controlled trial study design are suggested. Homoeopathic constitutional treatment has a significant impact on the QOL in patients with ESRD.
Keywords
Homoeopathy
Quality of life
End-stage renal disease
Constitutional
50 Millesimal
INTRODUCTION
End-stage renal disease (ESRD) is the irreversible deterioration of renal function to an extent that is incompatible with life without renal replacement therapy, either through dialysis or transplant. In such advanced renal pathology, the prevalent management method is haemodialysis. However, the burden of ESRD is on the rise.[1]
While haemodialysis is a lifesaving treatment, it is also known to create problems for patients. In clinical terms, it affects the quality of life (QOL). The WHO defines QOL as an individual’s perception of their position in life in the context of the culture and value systems in which they live as well as in relation to their goals, expectations, standards and concerns. It is a broad concept that is affected in a complex way by the person’s physical health, psychological state, personal beliefs, social relationships and their relationship to salient features of their environment. Assessment of the QOL is important in cases where the primary management comprises haemodialysis. Several studies are available that document the effect of haemodialysis on the QOL.[2,3]
Several reliable tools are available to assess the QOL in patients with ESRD on haemodialysis. The Kidney Disease QOL Short Form 1.3 (KDQOL SF 1.3)[4] is one such tool. The KDQOL SF 1.3 instrument is a self-report measure developed for individuals with kidney disease who are on haemodialysis. The KDQOL SF 1.3 incudes 43 kidney disease targeted items as well as 36 items that provide a generic core and an overall health rating item. This short form differs from the longer version 1.2 by adding a screening about sexual activity.
In haemodialysis, the body’s functioning is mechanically managed on a regular basis to ensure survival. However, as the QOL deteriorates,[5,6] the patient’s routine functioning is inappropriate and below the current standards of health. The patient’s social, emotional and physical spheres are deeply affected. They often develop post-dialysis symptoms such as cramps, hypotension and backache.[2] Emotionally, the patient is often depressed.[7] Social interactions, thinking capacities and intellectual activities reduce as well.[8]
During our initial interactions with patients undergoing haemodialysis when they filled the KDQOL, we noted that despite being aware that haemodialysis was a lifesaving procedure, the patients would describe the experience as ‘torture,’ ‘prison’ and ‘slavery;’ one patient attempted to be positive by stating that haemodialysis was ‘salvation.’ There are various studies linking patients on haemodialysis and poor QOL.[9] There is intense itching due to uraemia.[10,11] Studies show a higher incidence of depression in patients with ESRD, with a trend of increased deaths. There are studies indicating the relationship between QOL and morbidity and mortality.[12] Sleep is another parameter drastically affected in patients undergoing haemodialysis.[13] Muscular atrophy, aches and conditions such as restless leg syndrome are common as well.[14] Patients undergoing dialysis are reported to have a poorer QOL than the general population.[15]
Homoeopathic constitutional remedies are known to work on the ‘whole’[16] individual as mentioned in aphorism 2 and 6 of The Organon of Medicine. Thus, all the aspects of the patient’s well-being: mental, physical and social, are expected to improve; these are part of various domains of QOL. Improved QOL along with increased survival brings the patient closer to the complete definition of health. Several case reports show improvement in patients with chronic renal failure after homoeopathic treatment. Gupta. G, et al has shown the efficacy of homoeopathic medicines in patients undergoing haemodialysis with constitutional as well as organ-specific remedies.[17]
Ali, MK presented a conference paper on the role of homoeopathy in renal disorders.[18] Nikam, A describes several cases of renal failure wherein homoeopathy produced excellent results.[19] The efficacy of individual remedies in patients undergoing haemodialysis for example, China rubra, has also been studied.[20]
In such cases, the scope of a constitutional remedy holds a promise of action at all the above-mentioned levels, especially the LM potency. As the LM potency is the highest available scale of dilution at present, it is often recommended for use in cases with advanced pathology; it also has the least possibility of aggravations and adverse effects on the patients’ vitality.[21]
However, a well-documented study on the QOL on patients of haemodialysis managed with homoeopathy is not readily available. We, therefore, conducted this study to determine all the levels at which homoeopathy works in patients with ESRD undergoing haemodialysis.
MATERIALS AND METHODS
Three patients (two men and one woman; ages 38, 50 and 54 years), all Indians, agreed to be included in the study. The cases were managed with constitutional homoeopathic remedies in the 50 millesimal (LM) potency as an adjuvant to their current allopathic medications and were observed for 6 months. They were assessed with the Marathi version of the KDQOL SF 1.3 once before and after homoeopathic management along with regular haemodialysis.[22]
CASE REPORT 1
Date of case definition: 08 September 2018
A 38-year-old male, working as a deputy manager in a well-known bank was on haemodialysis for 2 years. At the time of case definition, the patient complained of severe post-dialysis cramps and mild itching of scalp (<sun +++, < warmth +++ and >cold bath). He also had a low mood, very poor socialisation, disinterest in social activity and reduced appetite. He was extremely sad and irritable3+ because of the on-going divorce with his wife. He had insomnia that persisted despite taking sedatives. The patient underwent dialysis thrice a week; his serum creatinine level was 10.1 mg/dL and the BUN level was 57.7 mg/dL, indicative of poor compliance toward dialysis. He also had fluctuation in blood pressure ranging from 180/110 to150/100 mmHg. The patient was diagnosed with ESRD due to hypertensive nephrosclerosis with ischaemic heart disease and depression not otherwise specified.
Totality
A/f Grief3+
Anger, with indignation+++
Anger hatred with +++
Weeping due to grief+++
Loneliness and forsaken lonely feeling+++
Dwelling on past disagreeable events +++
Brooding+++
Contradiction, intolerant of ++
Consolation ameliorates of specific people+
Desires pungent +++
Aversion – milk +++
Perspiration – profuse +++
In bus vomiting +++ (motion sickness)
Headache < sun +++
Skin itching < heat+++, <warmth +++, <sun+++ and >cold ++.
Case discussion
The case was understood by his characteristic reaction and ‘anger’ pattern as he was ready to compromise his life by missing the dialysis. He had marked persistent lonely and forsaken feeling since childhood that increased with age. The predominant theme was breaking of relationships. There was extreme disappointment due to the separation from wife, with inability to break free and move on from past relationship and extreme brooding.
Follow-up
The patient’s general level of sadness reduced; he could interact with the people around him. The skin complaint reduced by 70% and the post-dialysis weakness disappeared. He could sleep without sedatives. His blood pressure stabilised at 140/90 mmHg, and serum creatinine level stabilised at 6 mg/dL [Table 1].
Case report 2
Date of case definition: 31 January 2019.
A 50-year-old male patient who had completed the ITI certification but was presently unemployed. He would report to the dialysis centre in a wheelchair. His complaints were vomiting of food particles++ watery in nature, bilateral pedal oedema, decreased appetite, weakness and decreased urine output for 5 months. Vomiting <immediately after eating food++, <after drinking ++, uneasiness with sensation of discomfort. Reserved +++, aversion to company+++ always sitting at the beach. Sleeplessness+++ and restlessness+++ Abusiveness+++ alternating with depressed mood. The complaints of behaviour started after he was cheated by a colleague and lost his job. He was aggravated by loud noise+++, music +++ and if anybody came near him3+. His serum creatinine level was 8.72 mg/dL and BUN level was 87 mg/dL at the time of case definition. He had started dialysis in September 2018.
The patient also had hypertension for the past 5–6 years without regular treatment in the beginning.
| Follow-up criteria Date |
Sleep in hours and initiation | General weakness | Cramps in legs | Mood –depressed/anxious | Lower limb oedema | Skin itching | Bp [220/110] | Wt. Changes due to water retention | Serum BUN/serum creatinine | Prescription |
|---|---|---|---|---|---|---|---|---|---|---|
| September 6, 2018 | >++ | Sq | Occ. | >+ | + | + | Inc. 220/120 mmHg | Sq | [Aug] 115.4.mg/dL 12.1 mg/dL [Sept] 56.1 mg/dL 9.5 mg/dL |
Natrum mur 0/1 weekly three doses |
| October 11, 2018 | N | Lasts only 2 h post-dialysis | Just after dialysis/for some time | >++ | <+ | >70% | >+ [200/100 mmHg] | >++ | Improved. [oct.] 51.2 mg/dL 8.3 mg/dL |
Natrum mur 0/1 weekly daily dose |
| January 21, 2019 | Improved | SQ | 0 | 0 | +++ | Poor | Inc +[220/110 mmHg] | 0 | 52.7 mg/dL 10.17 mg/dL |
Natrum mur 0/2 weekly dose |
| February 11, 19 | > ++ | Improved | 0 | 0 | >20% | >20% | >+200/100 mmHg | 0 | 52.7 mg/dL 10.17 mg/dL |
Natrum mur 0/2 weekly three doses |
| March 7, 2019 | > +++ | Improved | 0 | 0 | >70% | >70% | >70% 140/90 mmHg | 0 | 43.7 mg/dL 6 mg/dL |
Natrum mur 0/2 daily dose |
The patient was diagnosed with ESRD due to hypertensive nephrosclerosis and mood disorder. All this information were obtained through the patient’s wife; he did not utter a single word. The patient avoided eye contact with anyone in the OPD and had an expression of hatred on his face. According to his wife, the patient is constantly in this state and refuses to even get up from his chair.
Totality
A/F – deceived, from being
A/F – grief
A/F – loss of job
Brooding
Company aversion to
Music aversion to
Desires – Seaside –
Sweets – Aversion
Fish – Desire
Meat – desires.
Case discussion
The case was understood based on the characteristic pattern of response of brooding and intense disappointment. Natrum mur came up as one of the highest in repertorisation. The pattern of break and disappointment in a single relationship is a hallmark of natrum group as per the modern understanding of the natrum group.[23,24] Natrum mur 0/1 was prescribed in one dose weekly for 3 months. The repetition was increased to thrice a week until 6 months consistently.
Follow-up
The patient was initially assessed with the KDQOL SF 1.3 in January 2019, when he consented to participate in the study. The second assessment was performed in July 2019 [Table 2].
Case report 3
Date of case definition: 04 October 2017
The patient was a 54-year-old female, housewife, married for 30 years with four sons and three daughters. She developed weakness +++ and breathlessness+++. She was diagnosed with chronic kidney disease Grade 1 due to chronic glomerulonephritis after her daughter’s marriage in November 2005. In November 2015, she had multiple episodes of generalised tonic clonic seizures. She had disorientation3+, drowsiness3+ and breathlessness+++ <night ++, <lying down and > lying on sides++. She was diagnosed with uraemic encephalopathy. A 2D Echo showed signs of concentric left ventricular hypertrophy; her left ventricular ejection fraction was 45%, indicating diastolic dysfunction. Her serum creatinine level was 9.9 mg/dL. This occurred after she had a dispute with her daughter-in-law; she had to start dialysis twice a week, which relieved her symptoms.
In August 2016, the patient developed breathlessness ++, heaviness of chest++, oliguria+ and abdominal distension++; she was admitted to our hospital and her dialysis increased to thrice a week. She then reported breathlessness <night ++, <lying down and > lying on sides++. These symptoms persisted despite the reduction in fluid overload due to the increased frequency of haemodialysis.
The final diagnosis was ESRD due to chronic tubulointerstitial nephritis and chronic glomerulonephritis with osteoarthritis and left ventricular hypertrophy.
Totality
A/f loneliness after daughter’s marriage
A/f suppressed anger and vexation+++
Weeping in anger+++
Weeping while talking about sickness
Fastidious +++
Uric acid diathesis
General exhaustion+++
P/H/O convulsions due to uraemia
Breathlessness +++
<night ++<lying down
>Lying on sides++
Air hunger +++ during breathlessness++
Sycosis.
| Follow -up criteria date | Sleep [initiation/dur/dist] | Appetite | Mood | Ability to carry out various activities at home [walking] | Socialisation [eye contact] |
Nausea | Vomiting | Serum BUN/Creat/urea | Prescription |
|---|---|---|---|---|---|---|---|---|---|
| January 31, 2019 |
+ | + | + | + | + | + | + | Natrum mur 0/1 once weekly |
|
| February 7, 2019 |
>75% | SQ | >+50-75% | SQ | >+ | 0 | 0 | 87.7 mg/dL/ 8.29 mg/dL |
Natrum mur 0/1 once weekly |
| March 4, 2019 to July 11, 2019 |
SQ, >++ (reduced duration), relief sustained | Improved consistently | >++, good | >+, progressed to >++ | >+, progressed to >++ |
0 | 0 | 65.9 mg/dL/ 7.52 mg/dL to 11.20 mg/dL/ 59 mg/dL |
Natrum mur 0/1 three doses weekly |
The patient was managed between 4 October 2017 and 30 April 2018 where she was partially better until she developed a different state of complete apathy and disinterest in life; seemed to be simply drowned in her sadness which was significantly observed from December 2017.
Investigation
CT scan brain December 8, 2017 showed fresh infarct in the left thalamocapsular region with subtle periventricular white matter changes and Corticocerebral atrophy.
However, Kali carb was continued for more 6 months from gradual onset of new symptoms from December 2017 until April 2018. The patient agreed to participate in the study and filled the 1st KDQOL SF version 1.3 in the month of April 2018. The patient’s totality was revised on 3 May 2018:
Revised totality
Ailments from grief
Company desire for
Consolation ameliorates
Fear of death
Indifference, apathy
Takes long time to reply
Brooding
Fastidious
Perspiration on face only
Aversion to meat.
Case discussion
The final remedy selected was Acid phos 0/1 single dose daily, based on the coexistence of extreme apathy and depression, along with the exhaustion and sleeplessness in night and sleepy during the day.
On 8 May 2018, a neurologist was consulted due to intermittent phases of disorientation and somnambulism for 10–15 days.
The neurologist recommended a 1.5 T MRI B stroke protocol and other investigations and advised to have the patient shifted to a tertiary care centre. Her family refused for investigations or referral to a higher centre; they accepted this as her last phase of life. The probable diagnosis was left middle cerebral artery infarct or small multiple infarcts. The patient also felt that these are her last days and she will not be able to see her youngest son’s marriage.
Understanding of the state: During treatment, the patient developed a peculiar state and had to be treated with a separate remedy after revising the totality.
In this case, loss of expressions was in itself a marked characteristic. Pathak describes in his Materia Medica, ‘Apathetic from unequal struggling with adverse circumstances, mental and physical.’ The mental state is one of sleepiness, brooding, aversion to business, indifference, hopelessness and despair. Correspondingly, in the body, there is weakness, lack of energy and disposition to lie down.[25]
Follow-up
The patient’s post-dialysis weakness reduced, her appetite improved by 70–80%, her socialisation and capacity to sit up were regained and she could eventually walk on her own. She could attend her son’s wedding with ease and comfort [Table 3].
She was assessed on a monthly basis. She was first administered the KDQOL SF 1.3 in May 2018, with a follow-up assessment in October 2018.
RESULTS
Results of the KDQOL SF 1.3 are given in [Table 4].
DISCUSSION
This study was conducted to find the scope of homoeopathic management on the QOL in patients with ESRD who were undergoing haemodialysis and were assessed with help KDQOL SF 1.3. After going through the results, we derived the following conclusions:
If we compare the scores[26] of each case, significant improvements are seen in the patient scores regarding the subjective conditions: Burden of kidney disease, cognitive function, quality of relationships, sleep, dialysis satisfaction, patient satisfaction, pain, emotional well-being and social and energy fatigue. These are the subjective sensations and emotions felt by the patient and observed by close relatives and acquaintances.
However, the rest of the parameters such as work status and sexual functioning showed no change in the score. Sexual functioning is part of the KDQOL SF 1.3 and hence even though patients have not mentioned anything, it is one of the 12 items of KDQOL SF 1.3.
The social support score improved in cases 1 and 2 but deteriorated in case 3. The physical functioning did not improve; in fact, the score was lower. No change occurred in the parameters of blood urea nitrogen or serum creatinine level as well.
| Follow-up criteria Date | Post-dialysis weakness | Appetite/stools/urine | Socialisation | Desire to work | Capacity for daily work | Pain in legs/ability to walk | Sleep | Prescription |
|---|---|---|---|---|---|---|---|---|
| March 15, 2018 | Sq | Reduced | nil | nil | No capacity | +++/nil | Nil in night/sleepy in day | Acid phos 0/1 weekly one dose |
| May 3, 2018 | Sq | Sq | sq | sq | sq | sq | 1–2 h at night/2–3 h awake in day | Acid phos 0/1 weekly three doses |
| June 2, 2018 | >20% | Improved by 30–40% | Improved by 60% | Improved 30% | >50% | 0/started standing on own | Improved by 30–40% | Daily doses Acid phos 0/1 |
| August 9, 2018 | >70–80% | Improved 50-60% | Improved by 80% | Improved by 50% | >60% | 0/Can walk on her own to dialysis unit from gate of the hospital unit [0.2 km] | 4–5 h night/2–3 h in day | Daily doses of Acid phos 0/1 |
| Parameters | Case 1 before treatment | Case 1 after treatment | Case 2 before treatment | Case 2 after treatment | Case 3 before treatment | Case 3 after treatment |
|---|---|---|---|---|---|---|
| Symptoms | 36.66 | 81.25 | 36.66 | 81.25 | 41.67 | 81.33 |
| Effects of kidney disease | 43.75 | 8.25 | 43.75 | 10 | 18.75 | 84.35 |
| Burden of kidney disease | 18.75 | 37.5 | 18.75 | 37.5 | 6.25 | 62.5 |
| Work status | 0 | 0 | 0 | 0 | 0 | 0 |
| Cognitive function | 33.33 | 66.67 | 33.33 | 66.67 | 33.33 | 40 |
| Quality of social inter-relationship | 26.67 | 66.67 | 26.67 | 75 | 93.33 | 86.7 |
| Sexual function | 100 | 83.33 | 100 | 83.33 | 0 | 100 |
| Sleep | 50 | 65 | 50 | 75 | 22.5 | 52.5 |
| Social support | 0 | 49.99 | 0 | 50 | 83.33 | 0 |
| Dialysis staff satisfaction | 62.5 | 100 | 62.5 | 100 | 50 | 75 |
| Patient satisfaction | 66.7 | 50 | 66.7 | 50 | 66.7 | 50 |
| Physical function | 50 | 15 | 50 | 75 | 95 | 35 |
| Role: Physical | 100 | 100 | 100 | 100 | 0 | 100 |
| Pain | 22.5 | 67.5 | 22.5 | 75 | 10 | 100 |
| General health | 45 | 45 | 45 | 45 | 20 | 30 |
| Emotional well-being | 20 | 60 | 20 | 80 | 0 | 84 |
| Role: Emotional | 100 | 0 | 100 | 0 | 0 | 100 |
| Social fatigue | 50 | 75 | 50 | 75 | 62.5 | 100 |
| Energy fatigue | 40 | 65 | 40 | 65 | 0 | 0 |
We observed that after the initial infrequent doses, frequent repetition was often required. This can be understood in the light of the patient’s susceptibility, which gradually decreases in the long term as these cases have advanced irreversible structural changes in the kidneys.
The application of the KDQOL SF 1.3 has helped to prove the scope of homoeopathy through an analytical way. However, there are multiple variables since dialysis is a dynamic event in itself and it affects the filling up of questionnaire like changes in fluid extraction may cause hypotension and for that day or week patient is uncomfortable in filling of the questionnaire. One needs to be well versed with the process of haemodialysis in general, to understand the variations it causes to a study. A larger sample size in further studies would prove more useful. An experimental study is obviously more fruitful than a case series. Case series is highlighting that there are significant changes seen through an universally accepted KDQOL SF 1.3. This article is intended to motivate researchers to create a pool of evidence slowly building up on this study where more work can be done eventually, opening the scope of homoeopathy in structurally irreversible and advanced stages. At times, homoeopaths claim to remove dialysis, but this has proved to be impossible and the only scope of homoeopathy is to show qualitative improvement.
CONCLUSION
The use of homoeopathy as an ancillary therapy in patients with ESRD was found to provide good palliative care. Homoeopathic management through constitutional prescriptions in LM potency was found to significantly improve the QOL in patients with ESRD. This improvement in the QOL was assessed using the KDQOL SF 1.3, where significant improvement in the scores related to several areas was noted.
Declaration of patient consent
Patient’s consent not required as patients identity is not disclosed or compromised.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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