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In ancient centuries urolithiasis was often a disease, with a catastrophic outcome all to often leading to the patient's death. Even today, urolithiasis is the one of the most $common affliction of the urinary tract" Detailed medical literature on urolithiasis is available from ancient lndia. As per classics, Ashmari is included in Ashtamahagada due to its fatal nature. Description of Ashmari is found in almost all Samhitas of Ayurveda as etio-pathogenesis, classification" s].symptomatically, complications and management in a most scientific manner. Modern science also emphasizes on involvement of various faction like heredity, age, sex, metabolic disorders, hydration status, mineral content of water, *nutritional! deficiency, etc. For urinary stone formation. Urolithiasis typically occurs in middle age which is the roust productive years of life. It causes pain, lass of nonworking time, medical expenses. needs for hospitalization as well as it is infrequent cause of renal failure and death.
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An Ayurvedic Approach in the Managcment *f Asltm&ri
Samaranayake, G.V.PI., Peiris, K.P.P2. and Pushpakumara,
rTemporary Lecturer, Department of Shalya Shalaky4 Gampaha Wickramarachchi Ayurveda
lnstitute, University of Kelaniya. Sri Lanka
2Senior Lecturer, Department of Shalya Shalakya, Gampaha Wickramarachchi Ayurveda
Institute, Universify ofKelaniya, Sri Lanka
3Senior Lecturer, Department of Shalya Shaiaky4 Gampaha Wickramarachchi Ayurveda
Institute, University of Kelaniya, Sri Lanka
Received: March 8,2019; Accepted: March 15,2019; Published: March 19,2019
Abstract: In aneient centuries urolithiasis was often a disease, with a catastrophic outccrme
all tao often leading to the patient's death. Even today, urolithiasis is the one of the most
$ommon aft'liction of the urinary tract" Detailed medical literature on urolithiasis is available
from ancient lndia. As per classics, Ashmari is included in Ashtam*hagada due to its fatal
nattrre. Description *f Askmari is found in almost all S*rnhitrs of Ayurveda as
etiopalhogenesis, classification" s].rnptomatcllogv, complicatians and management in a rnost
scientilic manner. Modern science also emphasizss on involvement of various facton like
heredify, age, sex, rnetabolic discrders, hydration status, mineral content of water, *utritiona!
deficiency, etc. For urinary stcne f<rrmation. Urolithiasis typically occurs in middle age which
is the ruost productive years of life. It causss pain, lass of rvorking time, medical expenses.
needs for hospitalization as well as it is infrequent cause of renal failure and death. Different
Ilrftnagement of urolithiasis has been developed in modern svstem but inspite of ail these
techniques, surgery remain treatrnent of choice. Even after surgery patients have to take
medicines to check its further recuffence. ln this *'ay the need of medicinal treatment is
always required.
Keym,o rds : As hm ar i, Uro I ithias is, As ht am ahagada.
Citation: Samaranayake., Peiris, K.P.P. and Pushpakumara, A.A.J- 2019. An
Ayun'edic Approach in the Management of Ashmari (Urolithiasis). International Joumal of
Current lnnovations in Advanced Research, 2{3): 13-22.
Copy'right: This is an open-access article distributed u*der the terrns of the Creative
Commons Attribution License, rvtrich permits unrestricted use, distribution, and reproduction
in any medium, provided the original author and source are credited. CopyrightO20lg;
Samaranayake, G.V.P., Peiris, K.P.P. and Pushpakurnara, A.A.J.
1. Introduction
Ashmari is known to mankind since times immemorial and it is one of the most common and
distressing disease among the group of urinary disorder. Susruta, the pioneer in the art of
surgery: during early civilization has described the problem o{ Ashmari rvidely and
comprehensively. The concept of Ashmari, its classification, symptomatology, etiologycal
factors, pathology, complications and management have been dealt with both medico-surgical
procedures. [ 1] Ashmari comprises of two words 'oAshma" and " Ari" . Ashma means "a stone
or gravel" and Ari means 'oan enemy". Ashmari is a disease in which there is formation of
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stone, exerting severe pain as given try enemJ*. Ashmari is considered as one of the
Ashtamahagada (i.e. one of the deadly diseases) by Susruta owing to its potentiality- to
ciisturb the urinary system. [2]
In Ayurvedic Iiterafure all sorts of methodologies including surgical techniques have been
described. Acharya Susruta said that before going for surgical procedures one should try rvith
oral medications like Ghrita (Medicated ehee). TaiLa (Medicated oil), Paneeya Kshara
(lvledicated Atkali preperation), etc. [3] *hich possesses the properties such as Chedema
(Cutting/ Brealiing), Bhedana (Splitting). Lekhdna (Scarification) and t'ulutrala (Diuretic) for
facilitating the disintegration of teh Urinarl stones.
The symptoms of Ashmari like excruciating pain or er \-abhi. Basti. At Sevani. Ar at Medhra
during micturition, sudden stoppage of urine flo*. blc.od stained urine. twisting and slitting of
urine, aggravation of pain during runnins. jolting etc. [4] go on in accordance rvith symptoms
of urolithiasis of modern science. Hence urolithiasis can be co-related with the Ashmari
mentioned in Ayurveda.
Urolithiasis is a multi-factoriaI disorder resulting from the combined influence of
epidemiological. biochemical and genetic risk factors. The effect of geographl on the
incidence of stone formation ma1' be through its effect on temperature as high temperature
increases perspiration which by increasing the concentration of urine promotes increased
urinary crystalization. The overall probability'of forming stones differ in various parts of the
world and is estimated about 1-5% in Asia" 5-9Yo in Europe, 13oh in North America and the
recurrence rate of renal stones about 75%o in 20 years span. [7] The disease afects all age
groups but typically occurs in middle life during the most productive years (30-50 years) rvith
male to female ratio 4:3. [6] The recurrent nature of stone diusease is a well-recognized
clinical problem. Urinary metabolic abnormalities such as low urine volume, hypercalciuria,
hvperoxaluria, hyperuricosuria and hypocitraturia predispose a patient to early reculrence.
Male gender, multiple stones, stone location, residual fragments and some anatomic or
functional urinary tract abnornralifies are known to be major risk factors for recurrence.
Primary stone formation and recurrence of stone formation is one of the biggest challenges
faced by urologists today and remain a major source of morbidity in humans. Despite
intensive studies in the last decade about many aspects of urolithiasis, the complete
pathogenesis and thus prevention, still remains to be clarified. [7] In modern sciences, various
treatment madalities are used to treat urolithiasis nowadays. But these methods of treatment
are having many draw'backs as given below-
l Medical expulsive therapy (MET). lt does not reduce the need of analgesiic. Retrograde
ejaculation and hypotension are also possible side effects.
2. Oral chemolysis is effective only for uric acid calculi.
3. ESWL (Extracorporeal Shock Wave Lithotripsy).
The success rate for ESWL will depend on the effrcacy of the lithotripter. size & location of
stone (ureteral, pelvic or calyceal), composition (hardness) of the stones & patient's habitus.
Further, severe obesity prevent targeting of stone. Anatomical obstruction distal to the stone
is also a contraindication to ESWL.
4. Endourology techniques
Percutaneous Nephroiithotomy (PCNl|*hances of heamorrhages are present. Perforation of
collectilrg system, colon & pleural cavity can also occur.[9]
Dormia basket & Ureter meatotomy for ureteric calculus have possibilities of ureteric injury
& urinary reflux respectively. [10]
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5. Open surgerj'-The incidence of open surgery is 1.59/o of all stone removal intenention in
developed country & in developing countries, it has been dropped from 26on to 3.5oh in
recent years due to its complexity. [1 l]
Due to the complexity of this disease and high chances of recurrence after surgical removal
Frere Jacques (The famous lifhotomist of Middle Ages) used to say * "I have rmoved the
stone, but God will cure the patient" [12]
6. Laproscopic surgery fbr removal of renal stones are invasive, have longer recovery time &
gteater risk of associated complications.
Thus in modern, the medical treatment is ineffective and lithotripsy or surgical techniques are
irrvasive, costly and often related with conrplications. Evan rnodem treatment is also not
sufficient to stop recurrence of urolithiasis. Ineffectiveness of modern treatment and an
alarming rise in the incidence of urolithiasis deals with a motivation provided by W.H.O.
(World Health Organization) to explore the possibility of discovering cure on traditional line.
It has created an impetus for further research in the light of Ayurvedic knowledge. Ayurveda
has mentioned different modes of trewatment of this disease by adopting the principle of not
only treating the disease but also preventing the recurrence of disease. Acharya CJzaraka has
described medicinal management whereas Acharl;a Susruta has described both conservative
as well as surgical removal of Ashmari.
2. Ashmari-
Formation of Ashma (stone) like substances within the urinary system is called Ashmtni.l'he
manifestation of any disease is described in five steps in Ayurveda that are Nidana,
Purlarupa, Rupa, []pashaya and Samprapthi. These are the five steps which helps the
physician I surgeon to reach at a proper diagnosis.
Nidana includes all thge etiological factors. The knowledge of Nidana is helpful for the
proper diagnosis, prevention of disease and treatment. Acharya Susruta has described the
causative factors of Ashmari. In person who do not undergo purification regularly and who
indulge in unhealthy foods and activities, kttpha gets aggravated, combines with urine,
reaclres the urinary bladder, staying tlrere and produces Ashmari. [14]
The symptoms of Ashmari we excruciating pain over Nabhi, Basthi, at Sevan[, or at Medhra
during micturition, sudden stappage of urine flow, blood stained urine, twisting and slitting of
usine stream, aggravation of pain during running, jolting. Etc. [1 5l Acharya Susruta describe
four types of Ashmari and gives importance to Shleshma (Kapha) in all type of ashmari.
Similarly in modern system of medicine also describe that the Urinary salts bound together
by a colloid matrix or organic materials. (shleshma) 116)
3. Urolithiasis II7l
Lithiasis occurs in various forms and at various sites in the body, most common sites are
urinary tract and biliary kact. Urolithiasis means the presence of a calculus in the urinary
system. Urinary calculus is a stone like body composed of urinary salts bound together by a
colloid matrix or organic materials; it consists of a nucleus around which concentric layers of
urinary salts are deposited.
4. Aetiology [18]
fhe cause of renal stone formation is not yet fully understood but in majority of cases
rnultiple factors are involved. Thye important factor which influence the formation and
growth of uroliths are as follorvs;
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Dietetic-Dificiency of r.itamin A causes desquamation of renal epifhelium &'hicll acts as a
nidus around for stone is deposited.
Climate-ln hot climate urinary solutes will increase with decrease in colloids, which leads to
chelation of solutes forming a nidus for stone.
Citrate level- resence of citrate in urine maintain the calcium phosphate and carbonate in
soluble state and any decrease in citrate level in urine causes stone formation.
Renal Infection- Infection favours the formation of urinary calculi. Urea splitting organisms
conrmon 11, eause stone forynation.
Prolonged immobilization--causes hypercalciuria causing nultiple bilateral stones.
lnadequate urinary drainage and urinan' stasis - Stones are lible to form when does not pass
Randall's plaque-Randall suggested that intialll a small erosion or ulcer develops at the tip
of renal papilla on which minute concretions or minor calcium particles get deposited and
give rise to stone formation.
Carr' postulates-states that minute concretions called as microliths normally develop in the
subendothelial part of the tubule which will be carried away as particles by'renal ll,mphatics
network vessels. If these lymphatics are blocked, microliths enlarge and act as nidus for stone
5. Risk Factors
Age p9l
Urolithiasis may occur at any age, but it is more common in between the third and fifth
decades of life. Urinarv calculi are unusual in children.
Urolithiasis is more liequently found in males then in fbmales. The male female ratio is 4:3.
Geography [20]
Though urinary calculi prevail everywhere in the world but there are few countries and
localities, which are more prone to this disease. The factor responsible for that are diet, water
and climate.
Protein rich Diet
Vegetarians are at lower risk for stone lbrmation in contrast to non-vegetarians. Animal
protein induces stone formation by different mechanisms. Protein are responsible for high
production of uric acid and excess excretion in urine may cause uric acid stone.
Protein ingestion generates renal acid Ioad that gives rise to metabolic acidosis where by the
urinary excretion of citrate is reduced.
Water [21]
Low fluid intake, excessive water losses in febrile disease and in hot climate leads to
supersaturation of urinary environment. Supersaturation of urine is a prerequisite for calculus
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fbrmation and increasect fluid consumption results in excreticn of higher volume of urine,
which is less supersaturated rvith stone-forming constituents.
6. Recurrence [22]
Urinary metabolic abnormalities such as lorv urine volume, hypercalciuria, hyperoxaluria,
hyperuricosuria and hypocitraturia predispose a patient to early recurrence. Male gender,
multiple stones, stone location, residual fragments and some anatomic or functr'onal urinarv
tract abnormalities are known to be major risk factors for recurrence.
7. T-vpe of stone [23]
Basically stones can be divided in to tw-o groups-
I) Primary stones
Are those lvhich appear in apparentll' healthl urinary, tract without any antecedent
inflammation. These stones are usuallr formed in acid urine. These stones ,rraily consists of
calcium oxalate, uric acid. urates. crstine. xanthine or calcium carbonate.
i) Calcium oxalate: This tvpe of stone is usualll single and is extremely hard. It is dark in
color afld irregular in shape and covered riith sharp prqections rvhich tend to cause bleeding.
This stone is popularll, knoun as jV1ulbern stone.
ii) Uric Acid and Urate Calculi: Thel' are hard. smooth and often multiple. pure uric acid
calculi are rare and not visible in X-ray. But in practice, majorit--r, of uric acid stone contains
some calcium so the)' cast a faint radiological shadow. These stones are usuailv occur in
multiple and so are typically faceted.
iii) Cystine calculi: They are rare. They are present in urinary tract of patients with a
congenital error of metabolism that leads to cystinuria. Cystinuria is found in young girls at
puberty. They are often multiple. These calculi are soft and yellow or pink in cotr. pu.e
cystine calculi are not radio-opaque, but as they contain suiphur they are usually radio-
iv) Xanthine calculi: These are extremely rare. They are smooth, round and brick red in color.
v) Indigo calculi: These are so uncommon that these are merely academic curiosities. These
are blue in color and are derived from indican, formed by decomposition of tryptophan in the
intestine and found in the urine.
I[) Secondary sfones
Are usually fb'rmed as a result of inflammation. The urine is usually alkaline, as urea splitting
organisms are most often the causative factors. Secondary stones are mostly composed of
calcium ammonium magnesium phosphate (triple phosphate).
i) Phosphate calculus
Majority of these stones are composed of calcium phosphate, though a few are composed of
arnmonium magnesium phosphate, known as 'triple phosphate'. Such calculus is usually
smooth' soft and fiiable' It is usually dirty white in color. This type of calculus usually occur
in infected urine. I-lrine is often alkaline. Such stone enlarges iapidly and gradualty iilts up
the pelvis and renal calycesto take up the shape of 'staghornlalculus,.
ii) Mixed stone
Phosphate stone may occur as covering of a primary stone. Such stone are known as mixed
8. Clinical Features
Following are the clinical fbatures of calculi lying in different positions.
Renal Calculi [241
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Those are very common. The symptoms are variable and the diagnasis sometirnes remains
obscure until the stone is discovered on radiography. Common symptoms are; Quiescent
calculus, Fixed renal pain at renal angle, reffered pain. hematuria, pyuria, hydronephrosis.
Ureteric Calculi [25]
Ureteral stone usually originates in the kidnel. Gravity and peristalsis both contribute to
spontaneous passage into and down to the ureter. If a renal stone passess to the urinary
bladder through ureter without any eyent, it is not detected. A ueteral stone is only detected
rvhen it causes some symptoms due to its presence in the ureter.
Ureteric colic, heamaturia, nausea and vonliting are the clinical features of ureteric stone.
Vesical Calculi [26]
Clinically three types of bladder stone are noticed.
t. Usual Bpe - which give rise to s)'mptorns
2. Silent type - which is asymptomatic
3. Masked type - in this t1'pe of stone. s\ mptoms of n stitis are dominant.
Frequency is more common during day than night. Pain and discomfort is particularly
cornplained of at the end ol micturition. Such pain rel-eres to the tip of the penis or labia
majora at the end of micturiation. pain or discomtbrt is also complained of in sumrapubic
region. Dysuria and hamaturiaare often terminal.
Urethral calculi [27]
Stone fiom the bladder is commonly passed out through if it is small, but the stone get
impacted due to a stricture or diverticulum. Migratory calcuii cause sudden pain in the
urethra soon after an attack ofureteric colic.
There is blockage to the flow of urine and if stone is small, the force of the jet will expel it
Ilom the external urethral meatus. Larger stone become stuck and may be palpable when it is
in the bulbar or penile urethra.
9. Chikitsa
1- Nidana Parivarjana (to avoid cause)
The main treatment of any disease is to avoid the cause. Ashmari is a Kapha dominant
disease. so all the measures that vitiate Kapha can be considered as cause of Ashmari.
Similarly, all the measures leading to the control of Kapha can be considered as Pathya.But
as urinary calculi are of different types, therefore some of its causes are common while some
are variety specific.
Common Cause to Avoid:
Ativyayama (excessive physical work or exercise), Adhyashana, Samashana, Sheeta,
Snigdha, Gtru, Madhura Aahara, suppresion of micturiation and defaecation and heavy diets
are freated as Apathya for Ashmari 1281.
Yyayama, Sctmdharana, Sushka, Ruksha Pishtanna, Vaata arka seyena, Yyavay, Kharjur,
Shalook, Kapittha, Jambav, Bisma (kamal moola), Kashaya rosa sevana etc.are also
considered as apathya for Ashmari [29]. Other causes leading to perspiration should also be
avoided. The ground water of some places contains excessive amounts of minerals contents
which produces the urinary calculi so such water sources should be avoided by boiling or
through filtration.
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Avoidaace of cause (According to fype of stone) [30]
Calcium oxalate calculi*Spinach, rhubarb, tomatoes, cashew nuts, cucumber, black tea, sogoa
asparagus, plums, strawberry and black gmpes contain high amounts of oxalate so these food
article should be avoided.
Uric acid calculi - Red meat, liver and fish are rich in purine so these food article should be
avoided. A low purine diet should be prescribed.
Cystine calculi-Sulphur containing proteins such as meat, fish and eggs should be restricted.
2. To Dilute the Urine
The priciple treatment of Ayurveda is to make the environment antagonist to the disease. As
the stone os formed due to concentrated urine. therefore opposite to it is dilution of urine.
When the urine is diluted it r.r'ill not onlr stop the further increase in the stone, but increased
hydraulic presurre in the kidney' ma1 also facilitate pushing of smal1 stone which passess
through urine.
By increase intake of water
By giving Mutral drugs - such as Punarnata. Kush, K"sh, Shttr Gctkshura. Ikshu, Kankola,
Hapusha etc. [31]
Punarrnva (Boerhavia dffisa.l-Mutral properfy is due to Madhura rasa and l,{adhara
Kush (Desmostachya bipinnata)-Mutral properfy is due to Madhura rasa and Madhura
Kaash (Saccharum spontaneum)-Mutral property is due to Sheet virya, Madhura rasa and
Madhura vipaka.
Gokshura (Tribulus terretris)- Mutral property is due to Madhura rasa and Madhura vipaka.
Shar (Saccharum munja)-Mutral property is due to Sheeta virya, Madhura rasa and
Madhura vipaka.
Il<shu (Saccharum fficinarum -Mutral property is due to Guru and Snigdha guna, Sheeta
virya, Madhura rasa and fuIadhura vipaka.
3. Ayurvedic Anti-stone Drugs
Ayurveda describes many herbs having stone breahing action. Along with above mentioned
measures when anti-stone drugs are used. the chances of breaking stone increases many
times. Following are well known plants with stone breaking agents.
P as hanabhe da (B er geni a ligulata)
Ashmari - bhedana property is due to Tridosha shamaka karma, Mutral karma and Lekhana
Varuna (C r at aev a nurv a I a)
Ashmari-bhedana, Mutral property is due to Prabhava. Shctshana of Kapha is due to Tikta
rasa, Kashayarasa. Laghu guna. Ruksha guna. Deepana property is due to (Jshnavirya.
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Kul attha {Dol irhos biflorus)
Ashmari-bhedana property is due to Laghu Rukshu Thikshna guna, Kashaya rasa and (Jshna
Yovaksharq (Alkali preperation of Barley)
Chedana, bhedana and lekhana property are due to prdbhava. [32] Antiurolithiatic activity is
due to alkaline nature. Diuretic activity is due to potassium salts.
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Urinary stone disease is an ailment afflicting human kind for many centuries. It can affect up to a quarter the population in certain geographic areas and hence poses a significant health problem. Various aetiological factors have been attributed to stone formation – hereditary, dietary, geographical, infective etc. Approximately 85% of the stones in human are calcium stones comprising oxalate and phosphate, either alone or combined. Though supersaturation of stone forming salts in urine is essential, abundance of these salts by itself will not always result in stone formation.The pathogenesis of calcium oxalate stone formation is a multi-step process and in essence includes – nucleation, crystal growth, crystal aggregation and crystal retention. Various substances in the body have an effect on one or more of the above stone forming processes, thereby influencing a person's ability to promote or prevent stone formation. Promoters of stone formation facilitate stone formation whilst inhibitors prevent it. Low urine volume, low urine pH, calcium, sodium, oxalate, and urate are known to promote stone formation. Many inorganic (eg. Citrate, magnesium) and organic (eg. Urinary prothrombin fragment 1, glycosaminoglycans, osteopontin) substances are known to inhibit stone formation. Organic inhibitory compounds adsorb to the surface of the crystal, thereby inhibiting crystal growth and nucleation. This review presents a comprehensive account of the basic principles of stone formation and role of urinary inhibitors/promoters in calcium oxalate crystallisation.
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The pharmaceutical industry is facing serious challenges as the drug discovery process is becoming extremely expensive, riskier and critically inefficient. A significant shift from single to multi targeted drugs especially for polygenic syndromes is being witnessed. Strategic options based on natural product drug discovery, ethnopharmacology and traditional medicines are re-emerging to offer good base as an attractive discovery engine. Approaches based on reverse pharmacology may offer efficient development platforms for herbal formulations. Relevant case studies from India and other countries where such approaches have expedited the drug discovery and development process by reducing time and economizing investments with better safety are discussed.
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Despite considerable progress in medical therapy, there is no satisfactory drug to treat kidney stones. Therefore, this study is aimed to look for an alternative treatment by using Achyranthes aspera. Here, the inhibitory potency of A. aspera was investigated on nucleation and the growth of the calcium oxalate (CaOx) crystals as well as on oxalate-induced cell injury of NRK 52E renal epithelial cells in vitro. Data are expressed as mean values of three independent experiments (each in triplicate) and analysed by the analysis of variance (P < 0.05) to estimate the differences between values of extracts tested. A. aspera extract exhibited a concentration-dependent inhibition of the growth of CaOx crystals but a similar pattern of inhibition was not observed with increase in the plant extract concentration for the nucleation assay. When NRK 52E cells were injured by exposure to oxalate for 72 hours, A. aspera extract prevented the injury in a dose-dependent manner. On treatment with the different concentrations of the plant, the cell viability increased and the lactate dehydrogenase (LDH) release decreased in a concentration-dependent manner. These studies indicate that A. aspera extract besides having a cytoprotective role also has a potential to inhibit both nucleation and the growth of the CaOx crystals and can prove to be a potent candidate for phytotherapy against urolithiasis.
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Medical management of urinary calculus disease is a challange for modern science. In the present trial Ayurvedic drug "Herbmed," which is made up of varuna (Crataeva nurvala) and banana stem (Musa paradisiaca) was assessed to see reduction and/or expulsion of urinary calculi and also to assess the role of these drugs to reduce pain during expulsion. In this prospective randomized, double-blind, placebo control trial, total 77 patients with calculi more than 5 mm were included. All patients were evaluated either by X-ray KUB or USG KUB for 3 months. All patients were divided into two groups: group A included patients with calculi 5-10 mm (n = 31) and group B with calculi > 10 mm (n = 30) with either active treatment or placebo in both the groups. All patients were asked to keep a record of number of pain episodes, while severity of pain was measured on a visual analogue scale (VAS). In group A, there was 33.04% reduction in the size of calculi in the active arm while there was a 5.13% increase in the same group in the placebo arm (p = 0.017). In the other group B, there was an 11.25% reduction in the active arm and a 1.41% reduction in the same group with placebo. In the active arm there was statistically significant lower VAS as compared to the placebo arm in the form of the highest VAS (p = 0.008), average VAS (p = 0.001) and VAS at the first episode of pain (p < 0.0001). Our preliminary experience suggests that the Ayurvedic formulation "varuna and banana stem" has promise for the management of upper urinary-tract calculi, especially renal calculi. It helps to dissolve renal calculi and facilitate their passage. In addition, it also helps in reduction of pain due to renal/ureteric calculus disease. A larger phase III study with a longer follow-up is required.
Background: Medical expulsive therapy (MET) using alpha blockers, calcium channel blockers (CCB), phosphodiesterase inhibitors (PDEI) and spasmolytics have been shown to be effective in clinical trials on urolithiasis. The present study is a network meta-analysis comparing the above mentioned drug classes. Research design and methods: Electronic databases were searched for randomized controlled trials comparing the above mentioned drug classes in patients with urolithiasis using appropriate search strategy. Inverse variance heterogeneity model was used for the mixed treatment comparisons. Stone expulsion rate (SER) was the primary and stone expulsion time (SET) was the main secondary outcome measure. Results: We included a total of 114 studies for systematic review and 108 studies for the network meta-analysis. Alpha blockers, PDEI, and combined alpha blockers and corticosteroids had significantly increased SER and shorter SET than placebo or standard of care. Alpha blockers have the highest probability of being the ‘best’ in the pool with regard to SER. This effect persisted in patients with stones ≥ 5 mm, children, after shockwave lithotripsy, proximal ureteric stones and distal ureteric stones. Conclusion: To conclude, we observed a statistically significant increase in the expulsion rate and shorter expulsion time with alpha blockers, PDEI and combined alpha blockers with corticosteroids. Of these interventions, alpha blockers have the high probability of being the ‘best’.
The main objective is to study the inhibitor effect of hydroalcoholic extract of Achyranthes indica Linn. on the crystallization of calcium oxalate in synthetic urine. Our study of the calcium oxalate crystallization is based on change in turbidity followed at 620nm by means of a spectrophotometer. The calcium oxalate formation is induced by the addition of 0.01M sodium oxalate solutions in synthetic urine. The addition of inhibitor with various concentrations (10%, 20%, and 40%) enabled us to give information on the percentage of inhibition. The comparison between the turbidimetric slopes with and without inhibitor gives the effectiveness of inhibitor for the hydroalcoholic extract. By comparing the photomicrographs of with and without inhibitor, we concluded that the extract of Achyranthes indica Linn. acts on nucleation as well as crystal growth stage. The hydroalcoholic extract of the extract of Achyranthes indica Linn. remarkably inhibits of crystal formation in calcium oxalate urinary lithiasis.
Objective: To study Acute, sub-acute oral toxicity profile of Herbmed plus (HP)-A herbal formulation.Methods: HP was derived from Crataeva nurvala Buch-Ham (Varun) bark, Musa paradisiaca Linn (Kadali/Banana) stem and roots, Achyranthes aspera Linn (Aghada) whole plant and Hordeum vulgare Linn (Yav) seeds. Above materials were converted into Varun bhavit kadali bhavit, kshars of Kadali, Aghada and Yav respectively and were mixed in certain proportions in GMP certified manufacturing facility to formulate HP capsules form remove soft gelatin. Acute and sub-acute safety profiles of HP was studied by OECD guidelines Number 423 and FDA guidelines in Swiss albino mice and Wistar rats respectively. For the acute study, HP was administered orally in a single dose of 2000mg/kg and for sub-acute study HP was administered orally using 90, 180 and 450 mg/kg doses for 90 days.Results: In an acute study there were no behavioral changes and mortality at 2000 mg/kg by the oral route in mice up to 14 days. In sub-acute study after administration of various doses of HP for 90 days to various groups; there was no significant difference in body weight, food consumption, hematology/enzyme profiles, relative organ weights and histological observations of vital organs in comparison to control animals.Conclusion: The acute LD50 cut off for HP was found to be > 2000mg/kg in mice and No Observed Adverse Effect Level (NOAEL) for HP was found to be > 450 mg/kg by oral route for 90 days in Wistar rats. © 2014,International Journal of Pharmacy and Pharmaceutical Sciences. All right reserved.
The cytoprotective action of lupeol isolated from C. nurvala stem bark against free radical toxicity has been investigated in experimental urolithiasis. Glycolate, an inducer of stone formation, significantly raised the renal tissue levels of calcium, oxalate, phosphorus and magnesium in calculogenic rats and brought about a remarkable decrease in kidney oxalate level. The increase in lipid peroxidation and superoxide dismutase (SOD) activity, associated with decreased catalase activity and glutathione (GSH) level are the salient features observed in tissues of stone forming rats. Lupeol administration induced a remarkable decrease in kidney oxalate level and also was effective in counteracting the free radical toxicity by bringing about a significant decrease in peroxidative levels and increase in antioxidant status. These observations highlighten the antioxidant property of lupeol and its cytoprotective action against free radical toxicity.