Using Homeopathy Case Taking, A Qualitative Study Was Carried Out on Ninety Cases of Chronic Kidney Disease Without Dialysis to Determine Management Guidelines

Management of chronic kidney diseases (CKD) and prevention of ESRD is highly required for population health and economic burden. Various factors other than diabetes, hypertension and drugs, are interlinked to main factors as well as directly causation to chronic kidney diseases (CKD). A homeopathic approach to finding out factors will help the prevention of ESRD and the curative aspect of the CKD


Introduction
Chronic kidney disease (CKD) is emerging to be an important chronic disease globally (Jha, 2013).Indeed, it has been recently estimated that the age-adjusted incidence rate of ESRD in India is 229 per million population, and >100,000 new patients enter renal replacement programs annually in India (Singh, 2013) .The Indian prevalence rate of CKD is around 17% (Abraham, 2018) and worse and CKD stage 3 is 6% (Singh, 2013) .Prevention of ESRD is highly required for population health and economic burden (Nugent R.A., 2011).Patients in the earlier stages of CKD have higher psychological challenges and psychiatric illness rates than the general population.These challenges may lower the perceived quality of life and progressive kidney disease in such patients (Harmon-Jones, 2013).High prevalence of psychological distress and depression among CKD patients as well as the need for specific mental health services to confirm the diagnosis and initiate effective management.Identified associated factors should be used to identify targeted preventative interventions (Gregg, 2021).Hypertension, diabetes and Drug history are the commonly known causes of CKD (kazancioglu, 2013), yet we couldn't prevent ESRD.We believe that the social environment is an important element in the pathway from CKD risk factors to CKD and end-stage renal disease (Gregg, 2021).Relationships between stress and pathophysiology are thought to be associated with alterations in the sympathetic/autonomic nervous system activity, the hypothalamicpituitary-adrenal axis, inflammatory cytokines, and endothelin-A (Bruno B. Lima, 2019), (DiBona, 2002), (Marino A. Bruce P. B., 2009).These alterations suggest that pathologic link between stress, hypertension, and CKD is possible as kidney sympathetic nerves innervate all segments of the kidney, and neural mechanisms regulate sodium and water retention (Amy H. Auchincloss, 2006), (Marino A. Bruce P. B., 2009) .It also has been suggested that stress may be linked to CKD via diabetes and insulin • Email: editor@ijfmr.comIJFMR240114010 Volume 6, Issue 1, January-February 2024 2 resistance.Environmental stressors have been found to be associated with the development of insulin resistance, metabolic syndrome, obesity, and ultimately type 2 diabetes (Ana V Diez Roux 1, 2002), (H.Black, 2003).The biologic link is thought to involve alterations in the neuroendocrine system including the hypothalamic-pituitary-adrenal axis (increased glucocorticoid and other stress hormones) in addition to sympathetic nervous system factors and inflammatory cytokines (Rosmond, 2005), (S R Silbiger, 1995).Stress also is thought to have implications in utero.The "Barker hypothesis" posits that disruption of the foetal environment or undernutrition translates into pathology (S R Silbiger, 1995).
From this we may concluded that stress or emotion is a key factor for hypertension, diabetes and genetic causation of CKD.Anger has always been included in the repertoire of basic emotions, mainly given its distinct and universally recognizable pattern of facial expression (AX, 1953).Anger is a strong reaction of both the sympathetic and parasympathetic branches of the autonomic nervous systems (Mimi R Bhattacharyya, 2007).Anger is often caused by some common trigger like dealing with the loss of a loved one, losing job, going through a breakup, being fatigue, failing at a job or task, physical changes in your body (K Iseki, 1996) .
Ninety non-dialysis CKD cases were included in a qualitative study to determine various factors related to CKD.A case-taking approach based on homeopathy was utilized to identify multiple factors in accordance with homeopathy, forming a management guideline for the preventive ESRD and curative aspects of treating chronic kidney disease (CKD).

Abbreviations and Acronyms
CKDchronic kidney diseases, GFR -Glomerular filtration rate, DMdiabetes Mellitus, HThypertension, NSAIDnon steroidal anti-inflammatory drugs, PPIproton pump inhibitors, Obstructive uropathystone or prostate lead to kidney failure, TBtuberculosis of lungs, Malignancyany carcinoma, separationwithdrawal him/her self from home, society, friends or forcefully push from home or society.MDC -Mental direct cause, MIDC -Mental indirect cause, NMC -No mental cause.

Method
Qualitative study done on ninety randomly assigned Non dialysis CKD (n = 90) patients.We obtained personal and medical history data through a homoeopathic case-taking interview method to find out a causative factors and management guidelines of CKD.Ninety CKD (without dialysis and transplantation) (n = 90) randomly assigned participants were taken with written and oral consent before case taking.Protocols approved by nephrologist institute.There was no age limit for participants.Both sexes included.Database maintained with written and audio recordings.Taken Open interview according to homoeopathic case taking for detailing the history.

Interview
The open interview was taken by a homoeopathic specialist as per the 6 th edition of the organon of medicine guideline.Assistance, nurses and other medical staff were trained by a homoeopathic physician.
From stages G1 to G5 without dialysis diagnosed cases were taken for study.Diagnosis of CKD, Diabetes, hypertension and other diseases did by a specialist allopathic physician.
In this study, Early menopause means age is 38 years before.In India, the range of mean age at menopause reported in different studies appears to be rather young, between 41.9 and 49.4 (Alka Kriplani, november, 2005).Drug history included mainly three groups I -NSAID (non-steroidal anti-inflammatory drugs), II -PPI (proton pump inhibitors), and IIIantiallergic medicine.Obstructive uropathy including renal stones leads to kidney injuries or failure.Renal stone surgery includes only surgery and has no direct correlation to CKD.Family history and addiction history are taken for non-direct correlation to CKD.Thermal history included body and weather reaction; Isensitive to heat, IIsensitive to cold, IIIno sensitivity to heat and cold.
Perceived stress scale (PSS) used to evaluate emotional stress intensity (Alexander Miller, 2018) .Following questions were asked to each patient and each question define with 0 to 4 score (0never, 1almost never, 2sometimes, 3 -fairly often, 4 -very often).1. l.In the last year, how often have you been upset because of something that happened unexpectedly?2. In the last year, how often have you felt that you were unable to control the important things in your life? 3.In the last year, how often have you felt nervous and stressed?4. In the last year, how often have you felt confident about your ability to handle your personal problems?5.In the last year, how often have you felt that things were going your way? 6.In the last year, how often have you found that you could not cope with all the things that you had to do? 7.In the last year, how often have you been able to control irritations in your life? 8.In the last year, how often have you felt that you were on top of things?9.In the last year, how often have you been angered because of things that happened that were outside of your control?10.In the last year, how often have you felt difficulties were piling up so high that you could not overcome them?severe perceived stress cases (more than 27 score) were considered for study and mental causative factor.
sMental history was broadly divided into two states of mind I-Anger and II -Mild, in which Ianger state in details with either suppressed or not, with expression (easily, out spoken, at workplace), with causation (contradiction, imperfection, dignity) and compare with separation.Separation history is included separation from family members or society either by withdrawing himself/herself or forcefully push away from home or the death of family members.Diseases felling is included with emotional state towards the diseases esp.CKD and are divided into I -Frivolous means no emotionality towards the diseases and II -Anxious means very emotional and cautious towards the diseases.

Statistics And Discussions
In the study, a total of 90 cases were taken for evaluation of the causes and factors of CKD.For homeopathic approach, taken the whole aspect of patients and history of personal habits, past, family, drugs, thermal, menstruation and mental.Selection of participants based on randomisation method and willingness in the study.CKDchronic kidney diseases, DMdiabetes Mellitus, HThypertension, NSAIDnon steroidal antiinflammatory drugs, PPIproton pump inhibitors, Obstructive uropathystone or prostate lead to kidney failure, TBtuberculosis of lungs, Malignancyany carcinoma, separationwithdrawal him/her self from home, society, friends or forcefully push from home or society.

Gender and sex
Previous studied showed that being of male gender was a significant risk factor for ESRD (adjusted odds ratio 1.41, 95% confidence interval 1.04 to 1.92) (K Iseki, 1996) .This is consistent with previous studies; male (masculine) patients (68%) are more than female (feminine) patients (32%).Sex differences involve rigid classification (i.e., male, female) by reproductive organs and their function and secondary sex characteristics.Gender distinctions involve categories (i.e., masculine, feminine) based on psychological and behavioural outcomes that are shaped by the surrounding cultural and social environment.Stress can be linked to gender disparities in kidney disease because stressors arise from one's social location and can have implications for health behaviours (Marino A. Bruce D. M., 2015) .Masculine nature was more significant risk factor for CKD so in female cases especially 24 % of cases had an early menopause, means who had lost early feminine nature.

Associated factors Diabetes and hypertension
In associated factors, history of hypertension (64.4%) and diabetes (48.8%) were the most common.According to previous study, in terms of risk factors, 87% were hypertensive and 37.5% had diabetes (Vivek Kumar, august 2021) .Hypertension was lower risk factors while diabetes was higher risk factors for CKD in our study as per comparison with previous study.This study demonstrated no synergic effect between diabetes and hypertension on the incidence of CKD (Erfanpoor S, 2021)

Drugs and addiction
Drug history was 34.4%, NSAID, PPI, and Anti-allergic was 20%, 11.1% and 3.3% respectively.The associated history of addiction was 37.7%, tobacco and alcohol was 27.7% and 10% respectively.In previous study, 16 %, 7.5% and 18.6% participants were current NSAID, alcohol and tobacco users, respectively (Vivek Kumar, august 2021).Drugs and addiction history is quite higher than previous study.

Past history
Renal stone surgery was 13.3% though which was not directly connected to CKD. 6.6% of cases started with obstructive uropathy and converted into CKD.As per study there was a no any significant past history.Further research should be required for correlation of past history and CKD.
Family history 20% cases had a family history of CKD.In this large population-based family study, a positive family history was strongly associated with increased risk of CKD, Heritability estimates of UAE, and UACR were 20%, and 18%, respectively (Jia Zhang, 2020), which was showed consistency same with our study.

Thermal history
Sensitive to heat, sensitive to cold and not sensitive to both were 44.4%, 14.4% and 52.2% respectively.Chilly patients were less in number showed that before onset of CKD patients not that much sensitive to cold.High temperatures are believed to predispose to renal disease due to heat-induced sweating, leading to decreased extracellular fluid (ECF) and subsequent dehydration [28].A proposed mechanism is that prolonged elevated vasopressin secretion, induced by chronic dehydration, contributes to progressive tubulointerstitial damage, predisposing to CKD [29,30,31].Sensitive to heat lead to a more dehydration and predisposed factor to CKD.

Mental history Mental factors
We found limited evidence to support an independent association of psychosocial factors with kidney health among black Americans [32].To verify this observation, we divided mental factors in to 3 categories I-direct mental cause means sever emotional stress leads to CKD incidence within 1 years of situation, not consider to mild and moderate emotional stress or more than 1 year duration of situation.IIindirect mental cause means sever emotional stress leads to associated disease like hypertension and diabetes within 1 year of duration of situation and that associated diseases lead to CKD incidence or increasing severity of associated diseases that lead to CKD incidence within 1 years of situation.III-no mental cause means moderate to severe emotional stress occurs yet not increasing severity of associated diseases or lead to direct CKD incidence.Mental factors associated was in 72.2 % cases (direct causative factors were 28.9%, indirect causative factors were 42.3%).According to Sri Lankan articles, the screening revealed that 75.0%(95% CI 72.5-77.5) of participants were psychologically distressed while 65.2% (95%CI 62.4-68.0)were found to be depressed with CKD [8].This result was consisting with previous study.

Anger vs Mild attitude
Many research related to anger or other emotions as a causative aspect of CKD yet very limited studies related to frequency or percentage of anger in CKD cases so difficult to compare with previous studies.In our study, anger attitude cases were 69 (76.7%) and mild attitude cases were 21(23.3%.).

Separation with other factors
Irrespective of separation types, studied and comparison was done with other CKD factors and anger emotion.

Sex, Gender and separation
Female cases with separation history (66 %) were higher percentage compares to male cases with separation history (57%).Feminine include gracefulness, gentleness, empathy, humility, and sensitivity though traits associated with femininity vary across societies and individuals, and are influenced by a variety of social and cultural factors [35].Separation is an emotional aspect and impact of separation is higher in feminine nature gender.In female cases, separation history as a mental cause of CKD (95 %) was higher percentage than male cases (83%).When separation as mental cause of CKD, brother separation was higher percentage in male cases (48%) while son separation was higher percentage in female cases (56%).

Age and separation
Dignity increased with age [24] yet tolerance level of emotional disturbance is high with age.50 years age and above cases had a higher separation history percentage (66%) compares to other age groups.Separation as a mental cause of CKD were 30 to 50 years age group had a higher percentage (90%) compares to other age groups.Impact of separation was higher in young and adult cases (direct mental cause 67%) compares to old age cases may be due to low tolerance level of emotional disturbance.All three age groups had equal types of separation.

Separation Types with percentage
Separation as mental cause in diabetes associated CKD cases (93%) were higher than hypertension associated CKD cases (89%) yet separation as a direct mental cause higher in hypertension associated CKD cases (50%) than diabetes associated CKD cases (42%).When separation as a mental cause, separation with brother percentage was higher and equal in both diabetes and hypertension were 38%, while separation with son were 35% and 31% respectively.

Drugs and separation
CKD cases with drugs and separation history were NSAID 45% cases (10 cases from 18) and PPI 50% cases (5 cases from 10).Separation as a mental cause of CKD with drugs history cases was in all separation cases (100%).Son separation was 60% in NSAID drug history cases.
Anger vs. mild attitude, suppressed anger and separation CKD cases with anger and separation history 59.4% (41 cases from 69) were lower than separation with mild attitude 61.9% (13 cases from 21).Separation and anger attitude history (90%) as a mental cause for CKD was higher than separation and mild attitude history (77%) as well as than anger without separation history (72%).Separation history with suppressed anger cases were 59.3% (16 cases from 27 suppressed anger cases).Suppressed anger with separation history as a mental cause for CKD was 100% (16 cases out of 16 suppressed anger cases) was higher significant compare to anger suppressed without separation history (77%).Suppressed anger with history of separation with brother, son and parents were 31%, 25% and 19% respectively.

Anger expression and causation with separation history
When separation history was presented in CKD cases, Out spoken expression of anger had a decreased percentage ratio (6.6%) than other two expression easily and at workplace had a increased percentage ratio, yet outspoken had a higher percentage ratio as a mental cause (direct and indirect).
All three causation factors of anger increased percentage ratio with separation history compares to nonseparation cases while dignity had a higher increased percentage ratio (5.6%) than contradiction and imperfection.As a mental cause of CKD, contradiction had a higher percentage ratio than two other causes of anger.Dignity as a cause of anger and separation history had increased percentage ratio for direct mental cause and decreased percentage ratio for indirect mental cause when compare to non-separation history as well as percentage value was 100% of mental causation factors for CKD with separation history.When separation was a mental cause of CKD, son separation (46%) was higher in cases where anger due to dignity.

Early menopause and separation history
All early menopause cases had a separation history (7 cases from 7).Separation as a mental cause of CKD with history of early menopause was 86% (direct and indirect both were 43%).When separation as a mental cause of CKD, son separation percentage was higher (57%) in early menopause cases.
CKD stages and separation CKD Stage 4 had higher separation history (66%) compares to other stages.Separation as a mental cause of CKD in stage 5 was a 100% while in stage 4, stage 3 and stage 2 was 86%, 85% and 50% respectively.Separation as a direct mental cause of CKD was higher percentage (64%) in CKD stage-5.When separation was a mental cause of CKD, son separation was a higher in stage 5 and stage 3 while brother separation was a higher in stage 5, stage 4 and stage 2.

Thermal history and separation
Sensitive to heat cases had a slightly higher separation history (58%) compares to sensitive to cold cases (54%).Separation as a mental cause of CKD was a higher percentage in sensitive to cold (100%) compares to sensitive to heat (83%).while separation as a direct mental cause of CKD was higher percentage in sensitive to heat (42%) compares to sensitive to cold (29%).When separation as a cause of CKD, son and brother separation almost same in both types of cases.
The end-stage of CKD was 22.2% in the observational study, to prevent dialysis and transplantation, such cases should be prevented from this stage through a holistic approach only because other than diabetes and hypertension there were many factors responsible to convert into ESRD.Early intervention may retard the progression of kidney diseases.All other specialist faculties than nephrologist alone as well as alternative medicine like homoeopathy and ayurvedic medicine play a crucial role in a holistic approach of treatment for prevention.According to Sri Lankan articles, Screening revealed that 75.0%(95% CI 72.5-77.5) of participants were psychologically distressed while 65.2% (95%CI 62.4-68.0)were found to be depressed [8].In our study mental direct and indirect causative factors shows 72% which is nearer to the previous study.It is a crucial time to involve a holistic approach to finding out the factors and curative method of CKD as well as the preventive aspect of ESRD.

Results
The mean age was 55.89 years and 68 % of them were males and 32 % were females.Causation factors were early menopause 24 % in females, a past history of obstructive uropathy was 7 %, with renal stone surgery was 13 %, family history of CKD was 20%, sensitive to heat was 44 %, mental factors associated was 72 % (direct factors were 29 %, indirect factors were 42 %), mental factors were anger 77 %, mild 23 %, suppressed anger 30 %, family separation history was 60 %, anxious about diseases was 84 %.

Conclusion
Early intervention may retard the progression of kidney diseases and dialysis or transplantation.Drugs will be selected according to all associated factors that will be highly required.It is a crucial time to involve a homoeopathic approach with management guideline to finding out the curative method of CKD as well as the preventive aspect of ESRD.

Table - 2 CKD causative factors comparison cases according to sex, Associated diseases, past history, family history, thermal sensitivity and mental sensitivity.
AgeCKD more commonly seen in above 50 years age (72%) [table-2].Loss of dignity generally raises greater concern among older inpatients (Brahm K Solomon, November, 2015) .In our study, if dignity issue as causation in above 50 years of age of CKD case, then it was present in 94% cases as a mental cause of CKD, so further research should be required for corelation with loss of dignity with increasing of age and CKD or ESRD cases.