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Zhang Daning, a Master of Traditional Chinese Medicine, is the Honorary President of Tianjin Academy of Traditional Chinese Medicine, as well as a Chief Physician, Professor, and Doctoral Supervisor. Master Zhang Daning possesses extensive experience in treating kidney diseases with Traditional Chinese Medicine. Below is a summary of his experience in using the modified Sishen Pill (Four Spirit Pill) to treat renal hematuria, shared for the benefit of colleagues.

Renal hematuria is one of the common clinical manifestations of kidney disease. According to etiology, it can be divided into two main categories: glomerular hematuria caused by various glomerular diseases and non-glomerular hematuria caused by other diseases. It is commonly seen clinically in conditions such as acute and chronic glomerulonephritis, latent glomerulonephritis, purpuric nephritis, and IgA nephropathy. Renal hematuria is characterized by recurrent episodes and a tendency to become chronic and difficult to cure. Modern medicine lacks specific therapeutic drugs and methods for it, and the therapeutic effect of using hemostatic drugs alone in Traditional Chinese Medicine is also not ideal.

Treatment According to Mechanism and Pattern

➤ Complex Patterns of Deficiency and Excess, Mutually Causal

Renal hematuria falls within the scope of traditional Chinese medicine categories such as "hematuria," "bloody urine," and "dysuria with blood." Its primary pathological factors involve four aspects: "deficiency, heat, dampness, and stasis." Renal hematuria is often a chronic condition; prolonged illness inevitably consumes the body's healthy qi, leading to qi deficiency and yang decline. Kidney yang is the foundation of the body's yang qi, and spleen yang relies on the warming of kidney yang. Prolonged yang deficiency inevitably damages the yang qi of the spleen and kidneys; therefore, in clinical practice, patients with renal hematuria of the spleen-kidney yang deficiency type are not uncommon. The kidney is the foundation of innate constitution, responsible for storing essence; the spleen is the foundation of acquired constitution, responsible for governing the blood. When spleen-kidney yang qi is deficient and weak, their functions of storing and governing become impaired, resulting in hematuria.

Zhang Daning believes that the pathological factors of renal hematuria of the spleen-kidney yang deficiency type are mainly two aspects: "deficiency" and "stasis." He considers spleen-kidney yang deficiency as the root cause and stasis obstructing the kidney collaterals as the secondary manifestation. When yang qi is deficient and weak, it fails to warm and propel blood circulation, leading to blood stasis. This stasis obstructs the kidney collaterals, causing blood to deviate from its normal pathways and extravasate from the vessels. In mild cases, this manifests as microscopic hematuria; in severe cases, gross hematuria may be visible. Spleen-kidney yang deficiency can lead to blood stasis, and blood stasis, as a pathological product, can further exacerbate yang deficiency. Thus, yang deficiency and blood stasis run throughout the entire course of spleen-kidney yang deficiency type renal hematuria.

➤ Ingenious Application of Classical Formulas in New Contexts

Zhang Daning believes that if a patient presents with microscopic or gross hematuria, accompanied by symptoms such as aversion to cold and cold limbs, pale and dull complexion, soreness and coldness in the lower back and knees, chronic diarrhea or dysentery or early morning diarrhea, thin and clear stool or undigested food in the stool, pale and dark tongue with white and slippery coating, and deep and choppy pulse, it can be identified as spleen-kidney yang deficiency type renal hematuria. Treatment should focus on warming and tonifying the spleen and kidneys, activating blood circulation and resolving stasis. The modified Sishen Wan (Four Spirits Pill) is selected, with the following composition: Psoraleae Fructus (Bu Gu Zhi), Myristicae Semen (Rou Dou Kou), Evodiae Fructus (Wu Zhu Yu), Juglandis Semen (Hu Tao Rou), Schisandrae Chinensis Fructus (Wu Wei Zi), Salviae Miltiorrhizae Radix et Rhizoma (Dan Shen), Chuanxiong Rhizoma (Chuan Xiong), Notoginseng Radix et Rhizoma Pulveratum (San Qi Fen), Astragali Radix (Huang Qi), Atractylodis Macrocephalae Rhizoma (Bai Zhu), Pseudostellariae Radix (Tai Zi Shen), and Cimicifugae Rhizoma (Sheng Ma).

In the formula, Psoraleae Fructus (Bu Gu Zhi) tonifies the fire of the life gate to reinforce fire and generate earth. Myristicae Semen (Rou Dou Kou) warms the middle and astringes the intestines. When combined with Psoraleae Fructus, it not only enhances the function of warming the kidney and spleen but also increases the effect of astringing the intestines and stopping diarrhea. Juglandis Semen (Hu Tao Rou) tonifies the kidney and secures essence. When used with Psoraleae Fructus, it can tonify the spleen and benefit the lungs above, and tonify the kidney and strengthen yang below. Evodiae Fructus (Wu Zhu Yu) disperses cold and stops diarrhea. Schisandrae Chinensis Fructus (Wu Wei Zi) constrains and secures. Chuanxiong Rhizoma (Chuan Xiong) activates blood, promotes qi circulation, and dispels stasis. Salviae Miltiorrhizae Radix et Rhizoma (Dan Shen) unblocks the channels, activates blood circulation, and dispels stasis. Notoginseng Radix et Rhizoma Pulveratum (San Qi Fen) stops bleeding without leaving stasis. Zhang Daning prefers to use a large dose of Astragali Radix (Huang Qi) (90–160g) to tonify kidney essence below and strengthen spleen qi above. When kidney qi is sufficient, qi transformation and containment are regulated; when spleen qi is vigorous, it can lift the clear and govern blood. Atractylodis Macrocephalae Rhizoma (Bai Zhu) and Pseudostellariae Radix (Tai Zi Shen) strengthen the spleen, benefit the lungs, tonify qi, and promote diuresis. Cimicifugae Rhizoma (Sheng Ma) lifts clear yang. When combined with Astragali Radix (Huang Qi) and Atractylodis Macrocephalae Rhizoma (Bai Zhu), it guides the herbs upward, synergizing the effects of tonifying qi and lifting. When clear yang ascends, the essence and subtle nutrients are secured.

Modifications based on symptoms: For severe blood stasis, add Pheretima (Di Long) and Hirudo (Shui Zhi) to activate blood circulation and unblock collaterals. For blood deficiency, combine with gelatinized Asini Corii Colla (E Jiao Zhu) to tonify blood and stop bleeding. For poor sleep, add Albiziae Flos (He Huan Hua) and Ziziphi Spinosae Semen (Suan Zao Ren) to nourish the heart and calm the mind. For liver constraint, add Bupleuri Radix (Chai Hu) and Paeoniae Radix Alba (Bai Shao) to soothe the liver and relieve constraint. For dampness encumbrance, add Pogostemonis Herba (Huo Xiang) and Eupatorii Herba (Pei Lan) to transform dampness with aromatic herbs. For soreness and weakness in the lower back and knees, add Eucommiae Cortex (Du Zhong) and Taxilli Herba (Sang Ji Sheng) to tonify the kidney and strengthen the lower back. For obvious edema, add Poria Cutis (Fu Ling Pi) and Mori Cortex (Sang Bai Pi) to strengthen the spleen and promote diuresis. At the same time, Zhang Daning emphasizes that when patients simultaneously have severe gastrointestinal diseases such as intestinal tuberculosis, tumors, or multiple colonic polyps, Sishen Wan should be used with caution or contraindicated.

The Four Spirits Pill originates from Xue Ji's "Internal Medicine Summaries" and is a renowned formula for treating fifth-watch kidney diarrhea. Due to its few ingredients, precise combination, and targeted efficacy, it has been highly esteemed by physicians throughout history and is widely used in clinical practice. With the continuous development of traditional Chinese medicine (TCM) and the advancement of herbal modernization, research reports on the Four Spirits Pill have increased, and its application scope has expanded further. It is not only used to treat digestive system disorders such as diarrhea and colitis but is also widely employed in the treatment of various diseases with spleen-kidney yang deficiency as the primary pathogenesis beyond gastrointestinal issues, including fifth-watch cough, infertility, enuresis, and low back pain. Zhang Daning's use of it in treating renal hematuria represents both a novel exploration of the clinical application of the Four Spirits Pill and an embodiment of the essence of syndrome differentiation and treatment—truly reflecting the principle that "same syndrome, same treatment; different syndrome, different treatment."

➤ Tracing the Roots, Differentiating the Syndrome to Find the Source

Syndrome differentiation and treatment are the fundamental principles of TCM in understanding and treating diseases. They are the enduring foundation of TCM and represent the most essential distinction between TCM and modern medicine. Syndrome differentiation is the prerequisite and basis for treatment, while treatment is the verification and practice of syndrome differentiation. However, in the treatment of renal hematuria, especially microscopic hematuria, some practitioners focus only on the external manifestations of the "disease" while neglecting the root cause of the "syndrome." They prefer to administer potent hemostatic agents, often achieving limited results.

Zhang Daning pointed out that ancient physicians were unaware of the concept of "microscopic hematuria." Patients with microscopic hematuria often experience no specific discomfort, and physicians could achieve results by employing the four diagnostic methods and applying syndrome differentiation and treatment. However, some contemporary practitioners rely solely on modern testing methods while abandoning TCM's principles of syndrome differentiation, which he views as putting the cart before the horse and should not be encouraged. Zhang Daning believes that contemporary TCM practitioners should view TCM's mindset and Western medical testing methods dialectically. When treating renal hematuria, they must adhere to TCM's principles of "treating the root cause of the disease" and "syndrome differentiation and treatment." He noted that although renal hematuria is a "bleeding disorder," it is essential not to focus solely on the symptom of hematuria by applying hemostatic methods or relying excessively on hemostatic drugs. Instead, treatment should be based on the patient's symptom characteristics, analyzing the specific etiology and pathogenesis, and applying syndrome differentiation and treatment for effective outcomes.

Typical Medical Case

Patient Yu, female, 52 years old. First consultation on July 20, 2016. The patient has had chronic nephritis for over 30 years with persistent microscopic hematuria to this day. Kidney biopsy pathology diagnosis: mesangial proliferative glomerulonephritis. Had intermittently taken oral Shenyan Kangfu Tablets, Shenyan Shu Tablets, and Chinese herbal decoctions for treatment with no significant effect. Sought consultation due to reputation.

Presenting symptoms: Low back pain, eyelid edema, aversion to cold with cold limbs, shortness of breath and reluctance to speak, normal urination but deep-colored urine, loose stools 3-4 times daily, dark tongue with thin white coating and tortuous sublingual collaterals, deep and thready pulse. Urinalysis: Occult blood (BLD) (+++), Red blood cells (RBC) 395.2/μL; Phase-contrast microscopy: Renal-derived red blood cells, Biochemistry (-). Denies history of hypertension, diabetes, etc.

Diagnosis: (Spleen-Kidney Yang Deficiency, Blood Stasis Obstructing the Kidney Collaterals pattern) Hematuria (Western medicine diagnosis: Chronic Nephritis).

Treatment Principle: Warming and tonifying the spleen and kidneys, activating blood circulation and resolving stasis.

Prescription: Psoraleae Fructus 30g, Evodiae Fructus 10g, Myristicae Semen 30g, Schisandrae Chinensis Fructus 30g, Salviae Miltiorrhizae Radix et Rhizoma 30g, Chuanxiong Rhizoma 30g, Notoginseng Radix et Rhizoma Pulveratum 12g (divided into 6 doses to be infused and taken separately), Astragali Radix (raw) 90g, Pseudostellariae Radix 30g, Codonopsis Radix 30g, Atractylodis Macrocephalae Rhizoma (stir-fried) 30g, Poria 30g, Cimicifugae Rhizoma 10g, Juglandis Semen 30g, Rubi Fructus 30g, Agrimoniae Herba 60g, Eucommiae Cortex Carbonisata 30g. Decoct in water for oral administration. One dose for 3 days. Decoct twice to obtain a total of 1800mL of decoction. Take 300mL each time, divided into morning and evening doses.

Second Visit on September 14th: Soreness, distension, and cold pain in the lumbar region; slight eyelid swelling upon waking in the morning; aversion to cold has improved; shortness of breath and fatigue; urine color has lightened compared to before; loose stool consistency, 2-4 times daily. Tongue: dark, coating white. Pulse: deep. Urinalysis: Occult Blood (BLD) (+), Red Blood Cells (RBC) 206/μL. The patient still presents with signs of Qi deficiency. Therefore, in the above prescription, Pseudostellariae Radix was removed, and Astragali Radix (raw) was increased to 120g to enhance Qi tonification. As the patient still has frequent bowel movements, Cinnamomi Cortex 30g and Chebulae Fructus Pulp 60g were added to support kidney Yang and stop diarrhea.

Third visit on December 24th: Occasional lower back soreness, urine color has lightened, no eyelid edema, reduced appetite, formed stools, 1–2 times daily. Pale-dark tongue with slightly greasy white coating; sunken and moderate pulse. Urinalysis: occult blood (BLD) (+), red blood cells (RBC) 105.4/μL. The patient exhibits signs of spleen deficiency with dampness retention. Based on the previous prescription, remove Rubus chingii to reduce its astringent effect, add Poria 30g, Chinese yam 30g, and coix seed 30g to enhance spleen strengthening and dampness elimination effects. Continue taking for 4 weeks to consolidate therapeutic efficacy.

Note: The patient has a disease course of over 30 years. Prolonged illness has led to deficiency of healthy qi and decline of yang. Spleen-kidney yang deficiency results in the spleen's inability to control and the kidney's failure to store essence and blood, causing blood to spill outside the vessels and manifest as hematuria. "The loins are the residence of the kidneys." Kidney yang deficiency leads to poor nourishment of the waist and spine, resulting in soreness and pain in the lower back. Spleen-kidney yang deficiency impairs the transformation of food and water, which flows downward into the large intestine, causing loose stools. The spleen governs the limbs; spleen yang deficiency results in poor nourishment of the muscles, leading to fatigue. Spleen-kidney yang deficiency disrupts the function of qi transformation, causing retained fluids to become water, which floods and overflows the skin, resulting in edema. Yang deficiency leads to cold, thus aversion to cold and cold limbs. A dusky tongue with thin white coating, tortuous sublingual vessels, and deep thready pulse are all signs of spleen-kidney yang deficiency.

The formula mainly uses Sishen Wan to warm and tonify the spleen and kidney, and astringe the intestines to stop diarrhea. It is combined with Sijunzi Tang to tonify qi and strengthen the spleen, with a heavy dose of raw Huangqi to tonify qi and raise yang. Danshen, Chuanxiong, and Sanqi powder are used to activate blood, resolve stasis, and stop bleeding; Duzhong Tan strengthens the loins and stops bleeding; Fupenzi is used for astringency and consolidation; Xianhecao stops bleeding and tonifies deficiency; and Shengma raises yang and lifts clear qi. All herbs work together to warm and tonify the spleen and kidney, resolve stasis, and stop bleeding. Zhang Daning's unique decoction method is to prepare one dose over three days. Depending on the patient's age, the decoction is boiled twice and combined, then simmered to concentrate into varying volumes: 300 mL, 600 mL, 900 mL, 1200 mL, or 1800 mL. For adults, one dose is concentrated to 1800 mL, taken as 300 mL each time, twice a day. This method enhances efficacy, avoids waste, and saves time and effort.