Patient's question:
At first, I had slightly swollen eyes at home. When I went to the hospital, I used eye drops for ten days, and the swelling on my face, abdomen, and feet became much worse. The doctor said it would be like this and that the swelling would only go down with frequent urination. It has been more than a month.Doctor's answer:
When it comes to the treatment of nephrotic syndrome, many patients often have the following doubts: Is traditional Chinese medicine better, or is Western medicine better? Is there an effective treatment method for nephrotic syndrome? To address this, we have specially invited Professor Cheng Zhenyuan, an expert in nephrotic syndrome treatment from Shijiazhuang Nephropathy Hospital, to explain relevant knowledge about nephrotic syndrome treatment.### I. Western Medicine Treatment for Nephrotic Syndrome
The common Western medical treatment for nephrotic syndrome involves the use of hormones, which are formally known as "glucocorticoids." These are normally secreted by the adrenal cortex in healthy individuals. Hormonal drugs include prednisone, prednisolone, and dexamethasone, among others. They have anti-inflammatory, anti-allergic, and immune-suppressing effects. For certain primary or secondary glomerular diseases, they can promote diuresis, reduce proteinuria, and protect kidney function. Therefore, they are commonly used in clinical practice for nephrotic syndrome caused by various pathological types, such as minimal change disease, mild to moderate mesangial proliferative nephritis, early membranous nephropathy, and proliferative lupus nephritis. Additionally, they are used in the early stages of rapidly progressive glomerulonephritis, active lupus nephritis, and acute allergic interstitial nephritis.
For severe mesangial proliferative nephritis, membranous nephropathy after stage 2, membranoproliferative nephritis, focal glomerular sclerosis, and other conditions that cause proteinuria, nephrotic syndrome, simple hematuria, acute nephritis, and chronic renal failure caused by various nephritides, hormones are not only ineffective but also have numerous side effects. These include drug-induced obesity, "moon face," "buffalo hump," muscle atrophy in limbs, skin cracking, euphoria, insomnia, osteoporosis leading to fractures, hypertension, diabetes, ulcer bleeding, perforation, poor wound healing, delayed growth in children, and secondary infections such as tuberculosis, staphylococcus, various Gram-negative bacteria, fungi, and viral infections due to immune suppression. These side effects are highly detrimental to patients. Especially in cases of concurrent infections, the inflammatory response may be mild, with low fever and pain, making it easy to misdiagnose. Infections are difficult to localize and prone to spread. Therefore, such medications should never be used casually. It is essential to select appropriate indications, avoid contraindications, and weigh the pros and cons carefully before prescribing.
### II. How to Maximize the Efficacy of Hormones?
How can we maximize the effects of hormones while minimizing their side effects? The basic principles of medication include "sufficient dosage," "single daily dose," "long-term treatment," "alternate-day dosing," "gradual reduction," and "integrated Chinese and Western medicine." Taking prednisone, the first-choice hormone in clinical practice, as an example:
- "Sufficient dosage" generally means taking 40–60 mg (8–12 tablets) daily.
- "Single daily dose" requires taking the medication in the morning after waking up. This allows hormones to fully exert their effects without suppressing the adrenal cortex's natural hormone secretion.
- After maintaining a daily morning dose of 8–12 tablets of prednisone for 2–3 months, the medication should be gradually reduced.
- "Long-term treatment" and "gradual reduction" mean that the course of treatment should be extended, and medication reduction should be slow. Abrupt discontinuation should be avoided to prevent symptom rebound.
- Clinically, we often use the "alternate-day reduction method," which has proven to be highly effective. For example, if prednisone is initially taken at 50 mg (10 tablets) daily in the morning, the reduction phase would begin as follows: On odd days (e.g., 1, 3, 5, 7), 50 mg (10 tablets) is still taken, while on even days (e.g., 2, 4, 6, 8), 1 tablet is reduced, to 45 mg (9 tablets) taken in the morning. After 1 week, on odd days, 50 mg (10 tablets) is maintained, while on even days, another tablet is reduced, to 40 mg (8 tablets) in the morning. After another week, on odd days, 50 mg (10 tablets) is maintained, while on even days, one more tablet is reduced, to 35 mg (7 tablets) in the morning. This continues until even days are skipped, and odd days begin to reduce the dose. Generally, the reduction follows the pace of 1 tablet per week.
- When the dose is reduced to 20 mg (4 tablets) on alternate days (with even days skipped, and 20 mg (4 tablets) taken on odd days in the morning), the reduction speed should be further slowed, as this stage is particularly prone to disease relapse. The reduction should be done with extreme caution. Typically, the dose can be maintained at alternate-day 4 tablets for over 6 months, and then gradually reduced.
- When prednisone is reduced to 10 mg (2 tablets) on alternate days, the medication should be continued for another 6–12 months before considering complete discontinuation.
Clinical observations have shown that this careful "alternate-day" and "gradual reduction" approach can significantly reduce disease relapse caused by rapid medication reduction and prevent adrenal cortex atrophy due to hormone-induced suppression of adrenal hormone secretion.
### III. How to Use Integrated Chinese and Western Medicine?
Regarding "integrated Chinese and Western medicine," this primarily refers to the combined use of Chinese and Western medications to consolidate hormone efficacy and reduce side effects.
Generally, when patients with nephrotic syndrome have severe edema, the initial use of hormones often aligns with a Chinese medical diagnosis of "spleen and kidney qi deficiency" and "internal retention of dampness." Chinese herbal medicines that can be used include Atractylodes rhizome, tangerine peel, dried magnolia bark, white atractylodes rhizome, poria, coptis root, cinnamon twigs, poria cocos, alisma, astragalus root, safflower, cardamom, corn silk, and cucurbita peel. Common formulas include Weilin Decoction, Coptis Poria Decoction, and Water-Leading Poria Decoction.
After a period of high-dose hormone use, side effects gradually manifest, and the Chinese medical diagnosis may shift to "kidney yin deficiency" and "internal heat and stasis." Chinese herbal medicines that can be used include rehmannia glutinosa, polygonatum sibiricum, lycium barbarum, epimedium brevis, anemarrhena asphodeloides, scutellaria baicalensis, phellodendron amurense, honeysuckle flower, Forsythia suspensa, salvia miltiorrhiza, and moutan root. Common formulas include Zhi Bai Di Huang Wan, Da Bu Yin Wan, Huang Lian Jiao E Jiao Tang, Zu Gui Wan, and Poria Decoction.
During the hormone reduction phase, especially when the dose is already low, adrenal cortex function needs to recover. The Chinese medical diagnosis may be "kidney qi deficiency" and "kidney yang deficiency." Chinese herbal medicines that can be used include epimedium, morinda officinalis, curculigo orchioides, psoralea corylifolia, cinnamon twigs, tribulus terrestris, eucommia ulmoides, dodder seed, astragalus root, angelica sinensis, rosehip, and lotus seeds. Common formulas include You Gui Wan, Xu An Wan, and Er Xian Tang.
During hormone use, if respiratory infections, sore throat with redness and swelling, or skin boils and facial acne with eczema and itching occur, the Chinese medical diagnosis may be "heat-toxin" or "damp-heat pathogen stagnation." Treatment should focus on clearing heat and detoxifying or promoting diuresis and detoxifying. Chinese herbal medicines that can be used include honeysuckle flower, Forsythia suspensa, impatiens balsamina, taraxacum mongolicum, dandelion, phellodendron amurense, baical root, scutellaria baicalensis, alisma orientale, dodder seed, and Sophora flavescens. Common formulas include Yin Qiao San, San Huang Wan, Wu Wei Xiao Du Yin, and Si Shen Tang.
If, during hormone use, symptoms such as mental excitement, insomnia with frequent dreams, restlessness, or even agitation occur, the Chinese medical diagnosis may be "kidney yin deficiency" and "heavenly and earth fire hyperactivity." Treatment should focus on calming the mind and spirit. Chinese herbal medicines that can be used include coptis root, scutellaria baicalensis, lotus seed heart, gardenia fruit, ophiopogon japonicus, rehmannia glutinosa, anemarrhena asphodeloides, pearl mother, oyster shell, polygonum multiflorum, ironwood, and iron fall. Common formulas include Huang Lian Jiao E Jiao Tang, Da Huang Huang Lian Xie Xin Tang, Dao Chi San, Qing Xin Lián Zi Yin, Tian Ma Gou Teng Yin, and Sheng Tie Luo Yin.
If, during hormone use, menstrual disorders, skin striae, dark tongue coating, or concurrent venous inflammation and thrombosis occur, the Chinese medical diagnosis may be "blood stasis stagnation." Treatment should focus on promoting blood circulation and resolving stasis. Chinese herbal medicines that can be used include angelica sinensis, ligusticum chuanxiong, persicae fruit, carthamus tinctorius, salvia miltiorrhiza, peony root, earthworm, manticore, and earthworm. Common formulas include Tao Hong Si Wu Tang, Salvia Miltiorrhiza Decoction, and Huo Luo Xiao Ling Dan.
In some cases during hormone use, if symptoms such as dizziness, heavy limbs, fullness in the chest and flanks, irritability, nausea, abdominal distension, poor bowel movements, and difficulty urinating occur due to the simultaneous presence of qi, blood, phlegm, food stagnation, dampness, and heat, treatment should focus on regulating qi and resolving stagnation. Chinese herbal medicines that can be used include bupleurum, magnolia bark, safflower, atractylodes rhizome, shenqu, gardenia fruit, ligusticum chuanxiong, peony root, white peony root, roasted bitter orange, pinellia ternata, and tangerine peel. Common formulas include Yue Ju Wan, Si Ni San, and Jia Wei Xiao Yao Wan.
In summary, while the efficacy of Chinese herbal medicine is slower, its effects are stable and have a strong synergistic effect when used alongside hormones. Not only does it enhance hormone efficacy and consolidate treatment outcomes, but it also reduces hormone side effects. Therefore, integrated Chinese and Western medicine treatment is preferable. Kidney disease patients should have a clear understanding of this.
Clinical treatment has shown that fewer than half of nephrotic syndrome patients are sensitive to hormones, and immunosuppressants also yield limited results. Among 1,450 cases of refractory nephrotic syndrome treated with Chinese herbal medicine as an adjunct to Western medicine, 1,210 patients developed resistance to hormones. After Chinese herbal treatment, 1,140 patients who were resistant to hormones became sensitive and improved.
In clinical practice, doctors should also apply the principle of "combining Chinese medical syndrome differentiation with disease differentiation" based on patient conditions, adopting corresponding treatment plans for different patients. As long as medications are used reasonably and care is provided appropriately, patients can recover.