A 48-year-old woman with a one-year history of severe proteinuria, elevated creatinine, and amenorrhea was managed using a Kidney-nourishing and essence-astringing herbal strategy.

Case ID: CHC-0048

Case Summary

This case describes a 48-year-old woman who presented with high urine protein and elevated creatinine levels originally discovered during a physical examination one year prior. The original report documented a conventional diagnosis of nephrotic syndrome and a TCM assessment of Consumptive Disease (Xu Lao) driven by Liver and Kidney deficiency, with the Kidney failing to secure essence. She was managed through a dynamic herbal approach based on a heavily modified Liuwei Dihuang Wan to nourish her foundational Yin, benefit Qi, and physically “lock” the leaking protein back into the body.

Patient Presentation

• Patient: 48-year-old female (Surname: Deng).
• Main Complaint: High urine protein, elevated creatinine, amenorrhea for 2 months, and hot flashes.
• History: The patient sought initial consultation on January 3, 2022. One year prior, a physical exam revealed severe proteinuria (+++) and elevated creatinine (178.3 µmol/L). She had been hospitalized at another facility and diagnosed with nephrotic syndrome, which had shown some improvement after previous TCM treatment. Her current presentation included amenorrhea lasting two months, hot flashes without sweating, a pale-sallow complexion, and a thin physique. Her blood pressure was 120/70 mmHg.

Examination and Diagnosis

• Conventional Diagnosis: Nephrotic syndrome.
• TCM Tongue and Pulse: The tongue was pale red with a thin, white coating. The pulse was fine (脉细).

TCM Assessment

The original practitioner interpreted the presentation as Consumptive Disease driven by Liver and Kidney Deficiency, with the Kidney Failing to Secure Essence (虚劳 – 肝肾不足，肾不固精).

According to the holistic principles of yin and yang Chinese Medicine the concept of “protein” in the urine perfectly aligns with the TCM concept of “essence” (精). The Huangdi Neijing (Yellow Emperor’s Inner Classic) states that the Kidney is the “root of sealing and storing.” When the Kidney is healthy, it firmly locks the body’s vital essence inside.

In this patient, the Liver and Kidneys were deeply deficient. Because the Kidney lost its sealing and storing capability, the vital essence leaked out into the urine (proteinuria). Furthermore, this severe lack of Liver and Kidney Yin meant her uterus lacked the blood to produce a period (amenorrhea), while the resulting empty fire caused her hot flashes. Her pale-sallow complexion and fine pulse objectively confirmed this deep systemic exhaustion.

Treatment Approach

The primary treatment principle was to nourish the Liver and Kidneys, benefit Qi, and astringe essence (滋补肝肾，益气涩精). The strategy aimed to physically rebuild the Kidney’s structural integrity while utilizing astringent herbs to forcefully plug the “leak.”

Herbal Formulas and Modifications

• Initial Formula (January 3, 2022): A 17-herb decoction built upon the classic Liuwei Dihuang Wan (Six-Ingredient Pill with Rehmannia).
  • Nourishing Liver and Kidney Yin: Shu Di Huang (24g), Shan Yu Rou (12g), Zhi He Shou Wu (20g), Gou Qi Zi (20g), and Sang Shen (20g) form a massive, heavy core to deeply replenish the exhausted Liver blood and Kidney essence.
  • Astringing Essence: Jin Ying Zi Rou (Cherokee Rose Fruit, 20g) and Tu Si Zi (Dodder Seed, 20g) are specifically utilized for their powerful astringing properties to physically secure the Kidney and stop the protein leakage.
  • Benefiting Qi and Spleen: Huang Qi (Astragalus, 20g), Bai Zhu (10g), Shan Yao (20g), Cang Zhu (20g), and Fu Ling (10g) fortify the Spleen to produce Qi. In TCM, strong Qi helps “hold” substances in place. Sha Ren (5g, added later) prevents these heavy tonics from causing digestive stagnation.
  • Clearing Heat and Draining Turbidity: Mu Dan Pi (19g) clears the deficiency heat (hot flashes), while Ze Xie (10g), Chuan Bi Xie (10g), and Che Qian Zi (10g) gently drain the damp-turbidity out through the urine.
  • Administration: 24 doses prescribed, 1 dose daily, water decocted, taken warm morning and evening.
• Second Visit (February 19, 2022): The patient reported poor sleep and many dreams. Laboratory results showed the urine protein had reduced to (++), but creatinine remained slightly high. The pulse was fine and slippery. The practitioner maintained the base formula but added Suan Zao Ren (Sour Jujube Seed, 10g) to nourish the Heart and calm the spirit for sleep. (24 doses).
• Third Visit (March 23, 2022): The patient’s night sleep significantly improved, and dreams decreased. Laboratory results showed a major breakthrough: urine protein further dropped to (+), and creatinine dropped to 128.1 µmol/L. To consolidate the emotional and sleep improvements, He Huan Pi (Albizia Bark, 20g) was added to the previous formula. (24 doses).

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is the direct TCM translation of a modern laboratory finding (proteinuria) into the classical framework of “leaking essence.”

Chronic nephritis and nephrotic syndrome are notoriously difficult to manage. The original practitioner’s commentary notes that regardless of the specific western label, the basic TCM pathology of proteinuria is a loss of “sealing and storing” (封藏). Even though the patient did not have severe, debilitating subjective pain, the practitioner strictly targeted the Kidney’s mechanism by heavily utilizing astringents (Jin Ying Zi, Tu Si Zi) combined with Qi-lifting herbs (Huang Qi). Over the course of three months, this strategy successfully rebuilt the Kidney’s “seal,” resulting in a dramatic, measurable reduction in both urine protein and creatinine levels.

---

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：六味地黄丸加减治疗蛋白尿案 Practitioner: Professor Zeng Xianjin (曾宪进) Publication date: September 15, 2024 Original language: Chinese ChineseHerb.org version: English translation and editorial adaptation