Volume 11, Number 3 | Fall 2016

Clinical Report 2 (Kampo Medicine)
A Case of Acute Exacerbation of Congestive Heart Failure withChronic Renal Failure Successfully Treated with Goreisan
Takahito Saito1)2), Yoshihiro Furuta2), Noriaki Ito2)
Kazuyoshi Higuchi2), Hideo Hirofuji2), Norimi Fujita2),
Hiroyuki Akane2) and Hiromichi Yasui2)
1) Medical Corporation Tomidahama Hospital,
2) Oriental Medicine Study Group ofYokkaichi Medical Association

Abstract
An 85-year-old man suffered from chronic renalfailure and congestive heart failure since about 2years ago. On May 12th in 2015, he admitted to thishospital due to acute exacerbation of congestive heart
failure presenting exertional dyspnea and thirst.
Together with resting on bed and oxygen inhalation,a new diuretics, tolvaptan, was taken in addition tohis conventional diuretic drugs. However, about 2
weeks later, tolvaptan was stopped because ofworsening renal function. Then, targeting to thirstand oliguria, goreisan was given for relieving clinicalsymptoms since June 3rd. Subsequently dyspnea andpoor appetite diminished at the end of June andbetter general condition continued more than one
month around the end of July.
We report a case of congestive heart failure
combined with chronic renal failure, successfully
treated with goreisan. In this case, goreisan improved
both acute exacerbation of the congestive heart
failure and the renal dysfunction with regulatingwater imbalance in body. Furthermore, it is very
important that his prognosis was prolonged withhighly quality of life.
Keywords: congestive heart failure, chronic renal
failure, goreisan, water balance regulation
Introduction
The pathologic condition of chronic renal failure
represents "water intoxication". Regardless ofwhether before or after dialysis, based on clinicalsymptoms like edema, dry mouth, vertigo, lassitude
and gastrointestinal symptoms etc. as well as
abdominal diagnosis, goreisan is the drug of firstchoice1). Here the formula is expected to help not only

to regulate water metabolism in the body, e.g.,
improve the condition of water intoxication, but also
blood pressure and delay the onset of dialysis2).
Congestive heart failure too, is also considered torepresent "water intoxication". In addition to rest andrestriction of salt intake western diuretics or
cardiotonic drugs are used for the treatment. To
rectify blood pressure or edema western diuretics(mainly loop diuretics like Furosemide orSpironolactone) are the standard therapy forcongestive heart failure3,4,5). However, an inattentive
increase in the dosage of loop diuretics may easily
lead to a deterioration of kidney function and thus
adversely affect the endogenous water balance.
Recently a new vasopressin receptor antagonists (adiuretic called Tolvaptan) has been added to thewestern diuretics, allowing to comparatively easily
achieve improvements of edema and congestion6).
On this occasion an elderly patient treated withloop diuretics was hospitalized because of a sudden
exacerbation of chronic renal failure complicated bycongestive heart failure. The patient was first treatedwith Tolvaptan, which was expected to improve theedema and congestion, but the drug was notsufficiently effective. After switching to goreisan,
however, the effects were even better than expected.
The here presented valuable case report indicates,that the diuretic action of goreisan could beconsidered due to it correcting the endogenous waterbalance and thereby improving various symptoms
including renal function.
Case: age 85, man
Chief complaint: exertional dyspnea, dry mouth
Past history: in 2002: fracture of left tibia and rightankle
Clinical course 1 (until admission):
Treatment for chronic renal failure complicated bycongestive heart failure on an outpatient basis wasinitiated approximately 2 years earlier. On May 12,2015 exertional dyspnea developed. On May 15 hevisited our hospital and was admitted for treatment
because of an acute exacerbation of the chronic renalfailure complicated by congestive heart failure.

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

23Volume 11, Number 3 | Fall 2016

Western medical findings:
Alert, height: 153 cm, weight: 56.5 kg, facial edema,
body temperature: 36.4°C, SpO2: 91%, BP: 137/71,
HR: 101/min, regular, cardiopulmonary: systolicmurmur, pulmonary rales, abdomen: flat, soft; edemaof the legs;
Oriental medical findings:
Subjective symptoms: exertional dyspnea, dry mouth;
Objective signs: inspection: poor complexion, earthen
colored; edema of face and lower extremities; pulse
diagnosis: deep, thin, weak; tongue diagnosis: thinwhite coat with dental impressions and engorgedsublingual veins; abdominal diagnosis showed lack ofstrength and softness of the lower abdomen.
Hyochondrial fullness and tenderness as well as
epigastric clapotage.
Examination results:
Blood examination:
white count: 3,500, hemoglobin: 7.4 g/dl, CRP: 0.61
mg/dl, urea nitrogen: 77 mg/dl, creatine: 5.02 mg/dl,eGFR: 9.3 ml/min/1, NT-proBNP 1,383 pg/ml,albumin: 3.3 g/dl;
chest x-ray: enlarged cardiac shadow, bilateral
pleural effusion, pulmonary congestion
Clinical course 2 (after admission): Figure 1

24

After admission the medication, including thewestern
loopdiuretics(FurosemideandSpironolactone) prescribed during the treatment as
an outpatient were continued. In conjunction withrest and initiation of oxygen inhalation the diuretic
Tolvaptan was added to the regimen on May 16, theday following admission. Yet, the dyspnea continued
and renal function deteriorated further. On May 29
administration of Tolvaptan was discontinued. Afterconsultation with the patient and his family it wasdecided not to initiate dialysis and insteadconservative treatment, including palliative care,chosen.
FromJune3
goreisan(Kotaro
Pharmaceutical Co., Ltd., 6 g/day) was added to theotherwise unchanged regimen in order to improve thesubjective symptoms of dyspnea, dry mouth and lackof appetite, targeting the dry mouth and decreased
urine volume. Later, body weight gradually
decreased and the pleural effusion decreased too. By
the end of June the dyspnea, dry mouth and lack ofappetite had improved. After a while, over a period
of about 1 month until the end of July, the generalcondition stabilized. By the end of August thepatient's general condition deteriorated because of
an infection and he died of multiple organ failure.

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 11, Number 3 | Fall 2016

Discussion

is precisely the manifestation of water intoxication.

Goreisan is comprised of the five crude drugs

Endogenous water balance in renal failure is marked

Alisma rhizome, Polyporus umbellatus, Poria cocos,
Atractylodes lancea rhizome and cassia bark. It is
widely used as a diuretic for intermediate conditions
between deficiency and excess with water
intoxication as its indication. In the classic Shan
Han Lun the pathologic condition is specified as thelesser yang disease state and the formula widelyused for dry mouth, diabetes, acute or chronic
nephritis, nephrosis, edema, uremia etc.1,2).

by an imbalance between the water of the blood andOn the other hand, western diuretics are used todisrupted water equilibrium in the body and should

reduce the preload, but even increase urine volume
when there is edema in the presence of dehydration.
In case of elderly people dehydration, electrolyte
anomalies, hypotension and similar conditions caneasily

complicate

thesituation,

sothattheadministered dose must be carefully considered3).
Taking the side effects of western diuretics like
Furosemide into account, in particular in case oflong-term administration, the dehydration may
possibly lead to renal dysfunction or cerebrovasculardisorders. Short-term combination with goreisan
while carefully observing the pathologic condition, orelse switching to goreisan to increase the diureticeffect, is also considered to be effective. When taking
the side effect dehydration into account, it is possible
to optimally utilize the advantage of goreisan topromote diuresis only in the presence of edema,possibly decreasing the side effects of western
diuretics.
Moreover, if a dose increase of the western
diuretics is in certain cases difficult due to thegeneral condition, combination with diuretic Kampo
formulas like goreisan can be effective. However,recently the western diuretic Tolvaptan has made its
debut on the clinical scene. Edema and congestioncan now comparatively easily be alleviated, the drugcauses only minor blood pressure fluctuations and issaid to be safer than western loop diuretics6). Some
reports have described the ease of water control
during the initial stage of dialysis7).
The pathologic condition of chronic renal failure

the water compartment outside of blood vessels. In
other words, the equilibrium between tissues andbody cavities has been disrupted. Moreover, while
there is excess water in the tissues and body cavities,
it cannot moisten the blood. goreisan adjusts thiscondition, supplies cells and the blood with waterand since it lowers osmotic pressure, during strong
inhibition of the diuresis, it ameliorates thetherefore be understood not to be simply a diuretic.
Regarding this property its effect can be expected todelay the the timing of dialysis initiation in cases ofrenal failure complicated by congestive heart failure.
Also, in cases of organic renal diseases it is by virtue
of its properties given priority over treatment withwestern diuretics and the guidelines pertaining
chronic renal failure as a chronic renal disease havebeen adjusted8).
Then again, congestive heart failure as apathologic condition too represents a true form ofwater intoxication. It is marked by progressive
intravascular dehydration and an excess of water in
the alimentary tract.
In case of organic disease, similar to organic renal
diseases, based on its properties, this formula should
be given priority over western diuretics. The details
have been arranged in form of the treatment
guidelines divided into acute and chronic cardiac
insufficiency6,7).

Cardiacdiseasesthatareindications for Kampo medicines are functional
disorders associated with cardiac neurosis. Again,
not so much the acute phase but rather the chronic
phase is the disease stage at which treatment isadministered. In case the western diuretics are
insufficiently effective, Kampo formulas are often
administered as required to alleviate symptoms,
promote diuresis and stabilize the general condition.
Moreover, in case a right heart insufficiency isobserved

whenconsidering

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Kampo

treatment25

Volume 11, Number 3 | Fall 2016

mokuboito (Mu Fang Yi Tang9)) may be one of thealso said to exert its effects via aquaporin6). In thischoices that can be used. To alleviate the symptoms

case Tolvaptan could not sufficiently exert its effects

of edema or cold pattern Kumibinroutou10) is also

because of the deteriorating renal function, but

said to be useful. Goreisan is often used in cases ofgoreisan was conceivably effective because ofheat pattern associated with a decrease in urine

differences between the two agents on the molecularvolume and edema. It can also be used for anasarca

level. A new disease concept "aquaporin disease" hascaused by cardiac insufficiency as well as a diuretic

been

in cases of pleural effusion due to congestive heart

diuretics, seems to be a formula with brightfailure during the still comparatively acute phase. It

prospects regarding its ability to prevent "waterismoving into directions generally not allowed".

considered

tocorrect

theintravasculardehydration and reduce the amount of excessive
water within the alimentary tract11,12).
This patient was a case of acute deterioration ofacute exacerbation of congestive heart failure or1.

2.

Goreisan on the other hand does not only improvein patient s hospitalized with worsening heart
failure: a randomized controlled trial. JAMA
2004; 291: 1963-1971
3.
4.

excess water into the blood vessels, it increases renal

diuretics through its regulation of the water balance

5.

delaying the timing of initiation of dialysis. We areexacerbation of chronic renal failure complicated by

6.

goreisanregulates

waterbalancevia

aquaporin13,14,15). Similarly, the diuretic Tolvaptan is

26

instruction

applicableintheofpatient

relatedtoKampo

Series;Kampo

future'Evidence based Clinical Practice Guidebook for

Treatment Guidelines for Acute Cardiac Failure(2011revisedEdition);

TheJapanese

Circulation Society
7.

Treatment Guidelines for Chronic Cardiac
Failure (2010 revised Edition); The Japanese
Circulation Society

8.

Ryukichi Matsui, Shotai Kobayashi: A case ofeffective treatment of recurrent pleural effusion

congestive heart failure will be a promising therapy.
Isohama is conducting research indicating thatcompliance'Practicedisease; 2013; Japanese Society of Nephrology

hoping that the comparatively early addition ofgoreisan to the regimen in this kind of acute–

Diagnosis and Treatment of Chronic Kidney

and was therefore considered to contribute toimprovements of clinical symptoms, ADL as well as

Trialogue

Medicine and Pharmacology: 2008; 16: 2-10

their effects. Thus, the diuretic effect of goreisan
improves the responsiveness to western loop

Masayuki Kashima, Hoko Amakata, Saori
Sakai:

Since it promotes the inflow of unevenly distributed

making it easier for western diuretics to recover

Shinichi Tashiro: Diuretic actions of goreisan;
Kidney and Dialysis (Supplement); 1989; 26: 34-37

the edema and congestion, but also renal function.

blood flow, which can be interpreted as helping

Gheorghiade M, Gattis WA, O’Connor CM, et al:
Effects of tolvaptan, a vasopressin antagonist,correlation called cardiorenal coupling. In spite ofdecreased renal function not very effective.

Sadayoshi Ito: Pharmacodynamics, mechanisms ofcardiorenal coupling; Circulation 2012; 2: 6-15

The heart and the kidneys maintain a close

diuretic Tolvaptan was probably due to thegoreisan, unlike westernactions, and usage of diuretics considering

acute exacerbation of chronic renal failure alone.

the presence of edema or pulmonary congestion theandReferences

chronic renal failure complicated by congestive heart
failure and not a single organ acute exacerbation like

proposedwith goreisan. Kampo Medicine 2006; 57: 339-334
9.

Hideki

Hashimoto:

Aofcardiac

failuremanifesting anasarca effectively treated withgoreisan. Journal of The Japan Society for
Oriental Medicine 2006; 57: 566

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 11, Number 3 | Fall 2016

10. Yoichiro Isohama: Water channel function
regulation

usingKampo

medicinesforinflammation / water intoxication; Kampo andLatest Therapies 2008; 17: D27-35
11. Yoichiro Isohama: Water regulation by goreisan
via aquaporin and inhibition of inflammatory
reactions; Kampo Medicine 2013; 37: 40-43
12. Yoichiro Isohama: The mechanism of regulation
by goreisan via aquaporin;

Kampo Medicine

2011; 35: 186-189
13. Toshihiro

Shigehara,

MarutoMurakami,

Takashi Araki et al.: Effective long-term
treatment of one dialysis patient with chronic
renal failure using Tolvaptan; Journal of theJapanese Society for Dialysis Therapy 2014; 11:691-696
14. Osamu Kinoshita: Usefulness of Boiogito forrefractory cardiac failure; Kampo Medicine
2004; 28: 73-75
15. Nobuyasu Sekiya, Mitsutoki Chino, Hirzo Gotoetal.:

IndicationandapplicationofKumibinroutou; Journal of The Japan Society
for Oriental Medicine 2006; 57: 333-338

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