Case Study: Kidney Yang Deficiency or Liver Yang Rising?

This month’s theme is men’s health and I find myself reflecting on the male principle, Yang. Many Traditional Chinese Medicine (TCM) practitioners learn that as they age, men become Kidney Yang deficient. Historically, I am sure that this has been borne out, yet in today’s modern world, at least in the US, most men rarely spend very much time working outdoors in cold weather or reside in homes and work in buildings without central heating, which are among the key factors that challenge someone’s Mingmen Fire. Of course, aging depletes Jing/Essence and consequently both Yin and Yang become somewhat depleted. However, in my experience, many men exhibit a greater tendency to Yin deficiency rather than Yang deficiency. This can develop when there is insufficient Yin to anchor the Liver Yang and, when added to emotional factors and stress, can become Liver Qi stagnation leading to Liver Yang or Liver Wind rising. The common assumption that men typically become Kidney Yang deficient can therefore cause a potentially serious error in treatment strategy, especially when using herbs.

Older Stressed Man

A Case History

J. P. is a 68-year-old male whose chief complaints are cold feet, intermittent low back pain, and chronic tinnitus, all of which have been getting worse over the past 5-7 years. He presents for an office visit because his new lady friend continually objects to his cold feet. “I guess it’s time to do something about it.” She thinks acupuncture can help.

Medical History and Narrative of present condition

Typical childhood diseases include a tonsillectomy at 9 y.o. and contracting mumps at 11, but without lingering effects. No history of injury or trauma, except for whiplash, lacerations, and a broken tibia from an auto accident at age 49.

Both of his parents are deceased. His father died twelve years ago at 72 of a heart attack, and his mother died 9 years ago at 73 of a cerebral vascular accident. He has an older brother who is in good health and a younger sister who has non-insulin dependent diabetes mellitus (NIDDM) and is obese.

Even though he is past the age he intended to retire, he continues to work at a stressful full-time job, where he is the owner of a foreign auto parts distribution company, which he has owned for 28 years. He says that although the company is financially successful, dealing with his customers and vendors over the years has been a source of continual frustration and aggravation. He has tried to sell the business for the last two years without success. His wife unexpectedly divorced him seven years ago and his three adult children are independent but frequently ask him for financial assistance. He cannot remember the last time he was on vacation. “I can’t afford to take a vacation. I work 60 hours per week. My business needs me.”

Inquiry

  • He reports that his feet have been cold for many years, even in warmer weather. They often have a kind of tingling, almost electrical feel. He denies any pain in his feet although he reports occasional spasms in his calves at night.
  • He experiences intermittent low back pain. “I can tell when I overdo it because my back talks to me. Usually, I only ache for a few days.”
  • His tinnitus is a constant buzz, “like a kind of static.” He says he has had it for twenty years, although he thinks it has become worse over time. An otoscope exam reveals only a slight accumulation of cerumen, and the ear drum is intact.
  • J.P. reports mild headaches 1-2x/week, usually temporal or parietal and almost always at the end of the week. Occasionally, his neck becomes stiff and painful. Sometimes, the headaches are severe enough that he will take acetaminophen, which usually takes care of it.
  • When asked about his emotional state, he says that mostly he is frustrated because of the nature of his work. “It's more high stress than you can imagine.” He complains about his suppliers, his customers, and his employees. When asked about his divorce, he expresses anger towards his ex-wife and blames her for the breakup. “She never appreciated how hard I had to work to keep things going.” He admits to sometimes losing his temper both with her and at work. “I have had to fire several employees over the past 10 years. Sometimes, I can’t control my anger and it boils over. I have to be by myself for a while so I can calm down.”
  • He reports no regular exercise program, and says he works too much to exercise. “I exercise everyday walking around the warehouse while I’m at work.”
  • He notes frequent but scanty urination, and says he often has trouble falling asleep. “I usually have a lot on my mind.” He wakes every night around 2am, “like clockwork” and gets up to urinate at least twice a night. “I also have vivid dreams which sometimes awaken me. It’s worse when things are difficult at work.” He does not feel rested when he wakes up.
  • He reports generally soft stools which are sometimes actually loose and watery. He says some foods “go right through me.”
  • While he denies any noticeable thirst, he sometimes awakens with a dry mouth. He never drinks “plain” water but consumes at least two, twenty-ounce Diet Cokes each day. He consumes a 12oz double latte with 2 tsp sugar and a pastry on his way to work and has an additional 3 to 4 cups of coffee each day with half & half and 2 tsp sugar at work.
  • Diet: standard American diet, does not like to cook, usually skips breakfast (except for his pastry and double latte), and always has fast food for lunch. “I’m a meat and potatoes kind of guy. I love BBQ.”
  • He stopped smoking cigarettes 15 years ago, and formerly smoked 2 packs / day.
  • Alcohol use: “couple of beers every night, just to unwind, you know.” Admits to drinking more at the occasional weekend events with his friends. Sometimes has rum or whiskey in his diet coke on the weekend.
  • Only uses cannabis socially. Denies ever using other recreational drugs.
  • Does not consider himself a spiritual person. “I never had time for that sort of thing.”

Medications

Takes Lisinopril (angiotensin-converting enzyme (ACE) inhibitor) “almost every day.” “I don’t like taking drugs and I never have, except for antibiotics a few times. He reports trying Vicodin (hydrocodone + acetaminophen) after his auto accident. “I didn’t like it. It knocked me out, my stomach felt queasy, and it gave me constipation for days. My doctor wants to make me take a statin, but I don’t want to. I don’t think I need it.”

Vital Signs

Height: 5’11”
Weight: 208 (self-reported)
BMI = 29.0, Waist= 38”
Blood pressure (in the office) =168/85
Pulse: 84bpm
SpO2= 97%
Temperature = 98.2°F
Resp.= 18/min. (shallow chest breathing)

Laboratory Tests

He reports that all his blood lab tests are okay, except his total cholesterol and “bad” cholesterol were “borderline” high. He thinks the total cholesterol was 230.

Palpation

Feet are moderately cold to the touch but not pale. There is no edema. His abdomen, low back, hands, knees are warm. Ren 17, 12, 4 are tender points, as are ST25, ST36, SP9, SP6, LV 3, LV14.

Pulse and Tongue

His pulse is thin and wiry, slightly rapid at 84bpm. His tongue is red with a rough and dry, thickish white coat. Slight teeth marks.

Assessment/Diagnosis

This patient’s diagnosis may be quite complex because there is a lot of interlocking syndromes involved. My diagnosis was Kidney and Liver Yin deficiency leading to Liver Qi stagnation and Liver Yang/Wind rising, with elements of Liver overcontrolling Spleen causing Spleen Qi deficiency and the accumulation of Dampness. Considering his chief complaints, I focused on the Liver Yang/Wind Rising.

Treatment Principle and Plan

Tonify Kidney Yin, Move Qi and Blood, Calm the Liver, Anchor the Yang. Acupuncture focused on opening the channels, moving Qi and Blood, and calming the Liver. Techniques included Aggressive Energy treatments and e-stim. An herbal formula of Tian Ma Gou Teng Yin Teapills was prescribed. He was also counseled about diet and lifestyle changes.

Discussion and Bottom Line

Tian Ma Gou Teng Yin along with acupuncture helped resolve his chief complaints, except for the tinnitus, and his blood pressure was somewhat reduced over the 4 weeks he came in for visits. He was amazed that his back pain was completely gone and that his feet were much warmer than before. Unfortunately, he was resistant to lifestyle and diet counseling and did not return after the initial progress.

Given this patient’s age, sex, and chief complaint of cold feet, many would attribute his symptoms to Kidney Yang deficiency. A thorough examination of the case finds there is a lack of evidence for this diagnosis. There are strong signs of Liver excess. The more likely alternative is that his cold feet are due to Liver Qi stagnation. He also exhibits a few signs of Kidney Yin deficiency, but often these are hidden by the Excess condition. When the Kidney Yin is deficient, excess Liver Yang or Wind can rise due to a lack of Anchor. In fact, Liver Yang rising presumes an underlying deficiency in either Yin or Blood (or both). Adding a Yang tonic or herbs that Warm the Interior and Expel Cold to this man would be a mistaken treatment plan that may have likely exacerbated his overall condition.

J.P. is, in my clinical experience, a typical American male. His circumstances, habits, lifestyle choices, diet, and emotional state are far too common among men, as is the diagnosis of Liver excess and underlying Kidney Yin deficiency, with Kidney Yang deficiency being relatively rare. I would emphasize that a thorough intake and careful diagnosis are requisite for the best therapeutic outcome.

Bio: Skye Sturgeon, DAOM, L.Ac.

Skye is the Quality Assurance Manager and Special Consultant for Mayway, USA. Skye was the former Chair of Acupuncture & East Asian Medicine and core faculty member at Bastyr University, core faculty member and Faculty Council Chair at the American College of Traditional Chinese Medicine, and President and Senior Professor of the Acupuncture & Integrative Medicine College, Berkeley. Before making Chinese medicine his career choice, Skye held various positions in the Natural Foods Industry for 12 years and prior to that was a clinical biochemist and toxicologist.
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