A 60-year-old man with a 20-year history of hypertension and recent severe lower limb fluid retention was managed using a Kidney-warming and water-draining herbal strategy.

Case ID: CHC-0037

Case Summary

This case describes a 60-year-old man who presented with bilateral lower limb edema that worsened in the afternoons, accompanied by cold limbs and fatigue. The original report documented a conventional diagnosis of endocrine dysfunction and hypertension, and a TCM assessment of Edema driven by Kidney Yang deficiency. The patient was managed through a dynamic herbal approach that prioritized warming the Kidneys to restore the body’s natural metabolic “pump” while safely draining the excess fluid.

Patient Presentation

• Patient: 60-year-old male (Surname: Xu).
• Main Complaint: Bilateral lower limb edema for over one month, significantly more pronounced in the afternoon.
• History: The patient sought consultation on February 28, 2018. He had a 20-year history of hypertension and was taking long-term antihypertensive medication. Over the prior month, he developed swelling in both legs. He sought treatment at another hospital with poor results before turning to TCM. The swelling was painless but exhibited deep pitting edema that was slow to rebound (按之凹陷难起). Associated symptoms included heart palpitations, chest tightness, an aversion to cold with cold extremities, severe mental fatigue, and a low volume of urine.

Examination and Diagnosis

• Conventional Diagnosis: Endocrine disorder; Hypertension.
• TCM Tongue and Pulse: The tongue was pale red with a white, greasy coating. The pulse was stringy (脉弦).

TCM Assessment

The original practitioner interpreted the presentation as Edema driven by Kidney Yang Deficiency (水肿 – 肾阳虚).

According to the holistic principles of yin and yang Chinese Medicine the Kidney’s Yang energy (often referred to as Mingmen Fire) acts as the body’s foundational metabolic pump, responsible for vaporizing and mobilizing fluids. The original report noted that the patient’s advanced age combined with decades of chronic illness (hypertension) had exhausted his Heart, Spleen, and Kidney Yang.

Because the “Mingmen Fire” was depleted, his body could no longer properly metabolize water. This stagnant water pooled downward, creating the severe pitting edema in his legs. The lack of Yang warmth failed to reach his extremities, causing his cold limbs and severe fatigue. Furthermore, the trapped water began to push upward to harass the Heart, resulting in palpitations and chest tightness. The pale red tongue, white greasy coating, and stringy pulse provided objective confirmation of this internal cold-dampness and fluid retention.

Treatment Approach

The primary treatment principle was to warm the Kidneys, assist Yang, transform Qi, and promote urination (温肾助阳，化气利水). The strategy required a balance of actively draining the trapped water while rebuilding the internal heat required to keep the fluids moving.

Herbal Formulas and Modifications

• Initial Formula (February 28, 2018): A 10-herb decoction drawing heavily from the concepts of Si Junzi Tang (for the Spleen) and Wu Ling San (for fluid metabolism).
  • Tonifying Qi and Nourishing the Heart: Tai Zi Shen (20g), Mai Dong (15g), and Fu Xiao Mai (30g) gently boost Qi and nourish the Heart to settle the palpitations.
  • Warming Yang: Gui Zhi (10g) paired with Zhi Gan Cao (10g) utilizes the classical principle of “combining acrid and sweet to transform into Yang” (辛甘化阳), specifically warming Heart and Kidney Yang.
  • Draining Dampness: Fu Ling (15g) and Zhu Ling (10g) strengthen the Spleen and promote urination to physically flush out the edema.
  • Moving Blood and Anchoring: Dang Gui (15g) and Chuan Xiong (10g) invigorate blood circulation, while Duan Mu Li (30g) anchors the spirit.
• Second Visit (March 6, 2018): The leg swelling had reduced, but the patient experienced a dry mouth. The practitioner removed the warm, dispersing Gui Zhi. Fen Ge (30g) was added to generate fluids and relieve the thirst, while Ze Xie (15g) and Che Qian Cao (30g) were introduced to strongly enhance the water-draining and swelling-reducing effects.
• Third Visit (March 14, 2018): The afternoon edema was largely gone, with no pain. With the bulk of the pathological water cleared, the practitioner removed Fen Ge and Mai Dong. To consolidate the cure, Bai Zhu (20g), Gui Zhi (15g), and Ji Xue Teng (20g) were added to deeply strengthen the Spleen, nourish the blood, and restore the warming Yang.

Follow-Up

• After the third visit and completing the final seven doses of the consolidated formula, subsequent follow-ups reported that the bilateral lower limb edema was entirely cured, with the patient experiencing no further discomfort.

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is the sophisticated management of refractory edema in an elderly patient with chronic cardiovascular disease. In conventional medicine, resistant edema is often treated by simply increasing the dosage of loop diuretics, which can further exhaust the patient’s kidneys and electrolytes.

The original practitioner recognized that the edema was not a primary kidney failure, but rather a “pump failure” (Kidney Yang Deficiency). If they had only prescribed heavy water-draining herbs, the patient’s weak constitution would have collapsed. By seamlessly integrating warming herbs (Gui Zhi), Qi-tonifying herbs (Tai Zi Shen), and blood-invigorating herbs (Dang Gui, Chuan Xiong) alongside the natural diuretics (Zhu Ling, Ze Xie), the treatment successfully restarted the body’s internal metabolic engine. This ensured the fluids were cleared safely and permanently without further damaging the patient’s foundational energy.

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What This Case Can — and Cannot — Tell Us

This is an individual case report, not a controlled clinical trial. It documents the reasoning, treatment, and outcome reported for one patient and should not be interpreted as evidence that the same approach will produce the same result in another person.

Source

• Original source: Qingyuan Maternal and Child Health Hospital / Guangdong Provincial Administration of Traditional Chinese Medicine
• Original title: 【以案说医】曾宪进：温肾助阳，化气利水法治疗水肿案
• Practitioner: Professor Zeng Xianjin (曾宪进)
• Publication date: September 26, 2024
• Original language: Chinese
• ChineseHerb.org version: English translation and editorial adaptation