The patient’s chief complaint was positive urinary protein and elevated serum creatinine (Scr) levels.

A 28-year-old man had positive urinary protein (++) and elevated Scr (149 μmol/L) test results in 2014. He underwent renal biopsy in February 2015 and was diagnosed with “IgAN, mesangial proliferative glomerulonephritis with sclerosis”. Since then, the patient had been taking losartan (100 mg daily) and ketosteril (α-ketoacid tablets; 2.52 g/3 times daily). He first visited the outpatient department at our hospital on June 1, 2017. At this visit, malaise, waist soreness, acid reflux, and bubbles in the urine were the main clinical manifestations. The patient also complained of frequent urination at night. His tongue was light red with a yellow coating, his pulse was slippery (meaning that his pulse was beating freely and smoothly like the movement of abacus beads), and his pharynx was red.

The patient visited the outpatient department again on August 2, 2017. At this visit, waist soreness and fatigue were resolved. The patient’s stomach discomfort was also alleviated. However, he still had a sore throat and spermatorrhea.

At his 3^rd visit on September 28, 2017, serological indexes were stable. Clinical manifestations such as waist soreness, fatigue, pharynx discomfort, spermatorrhea, and epigastric discomfort were unchanged.

At the 4^th visit on October 26, 2017, serological indexes had decreased significantly. The patient’s epigastric discomfort had improved, but waist soreness remained.

At the patient’s 5^th visit on November 23, 2017, his clinical symptoms including waist soreness, fatigue, spermatorrhea, and epigastric discomfort were all resolved, and the serological indexes had also decreased.

The patient has no history of a relevant illness.

The patient has no family history of a similar illness.

On admission, the patient’s blood pressure was 120/80 mmHg, and no abnormalities were detected during the physical examination, including the cardiopulmonary system. There was no edema in either lower limb.

The serological and urinary indexes are shown in Table 1.

Renal ultrasound showed no obvious abnormality.

Under light microscopy, a renal biopsy sample contained 25 glomeruli, among which there were 15 glomeruli with global sclerosis and no crescent. The remaining glomeruli were enlarged with approximately 90-110 cells/glomerulus. There were some mesangial areas with severe matrix hyperplasia with 2-3 cells/mesangium. The basement membrane was normal and the structure of capillary loop remained open. Complete sclerosis was seen in some glomeruli. Masson Stain was negative.

There were moderate lesions in the tubulointerstitium with indistinct tubular structure, no tubular atrophy, some swollen and degenerated tubular epithelial cells and some vacuolar degeneration. Focal fibrosis (40%) and more inflammatory cell infiltration could be seen in the interstitial area.

Immunofluorescence showed classic prominent IgA deposits.

IgAN is in the edema and hematuria category in TCM[18]. In ancient times, doctors had a comprehensive theory on pathogenesis, diagnosis, and therapy for kidney diseases, as recorded in the Yellow Emperor’s Canon of Medicine Plain Conversation: “All dampness, swelling and turgidity is ascribed to the spleen.” Professor Zou proposes that IgAN pathogenesis is a mixture of deficiency and excess. Patients with IgAN are susceptible to outer pathogen infection because of lung Qi deficiency, in accordance with TCM theory. Qi deficiency in the kidney, spleen, and lung is the internal basis that contributes to damp-heat production as a pathological factor throughout the course of IgAN. Additionally, the long-term existence of the dampness pathogen suppresses Qi and leads to Qi stagnation. Qi stagnation makes it difficult for blood to circulate smoothly. In summary, the main cause of IgAN is derived from kidney, spleen and lung deficiency, which is accompanied by dampness, damp-heat, blood stasis and wind-pathogen. Improving deficiency and eliminating excess pathogenic factors constituted Professor Zou’s main clinical therapeutic strategy.

In this case, Professor Zou initially distinguished between deficiency syndrome and excess syndrome, giving consideration to both improving the deficiency and expelling pathogenic factors. The patient was treated on the basis of the disease stage and its course. In the early stage of therapy, pathogenic factors were prominent. Professor Zou strengthened the therapy of purging turbidity and detoxifying to gradually eliminate the damp-heat and blood stasis from the body. Malaise and waist soreness in the morning indicated kidney and spleen deficiency, while acid reflux, increased Scr and UA levels and bubbles in the urine demonstrated turbidity and dampness. She used treatment measures to tonify the kidney and spleen, purge turbidity and clear dampness, promote blood circulation and remove blood stasis. After the first treatment, the waist and stomach symptoms were relieved and serology indexes were improved. However, the patient’s throat discomfort and an increase in spermatorrhea demonstrated persisting kidney deficiency. At the following visits, the deficiency syndrome was the main target. Professor Zou strengthened the therapy of invigorating the kidney, spleen and lung to improve Qi. Throughout the disease treatment, Professor Zou focused on tonifying the kidney and spleen and clearing away damp-heat. After almost 6 mo of treatment, the patient’s symptoms were resolved, and Scr and UA levels were significantly lower. There was an increase in the UA level on January 18, 2018, which may have resulted from the previous cold or the patient’s overeating. These were not recorded and overall, the UA level trended downwards. Over the subsequent follow-up, renal function remained stable.

For herb selection, Professor Zou prefers mild and gentle herbs to invigorate the kidney and spleen because warm and hot drugs can easily hurt Yin, and greasy drugs can easily cause dampness stagnation. She uses drugs such as: (1) Taizishen (Pseudostellaria heterophylla); (2) Shenghuangqi (Radix astragali); (3) Chaobaizhu (fried Rhizoma atractylodis macrocephalae); (4) Shengyiyiren (Semen coicis), (5) Fuling (Poria); and (6) Fushen (Poria cocos). Furthermore, the mechanism of kidney diseases in TCM theory is the disorder of Yin and Yang in the lower abdomen (Xia-jiao), and it is difficult for the herbs to reach the disease center because Xia-jiao is located in the lower part of the body[19]. However, the course of kidney disease is often long and persistent. Professor Zou used a combination of herbs and larger drug doses to balance Yin and Yang in the lower abdomen. The following herbs are often used for purging turbidity and detoxifying: (1) Huangshukuihua (Abelmoschus manihot); (2) Shiwei (Pyrrosia sheareri); (3) Yinchen (Herba artemisiae scopariae); (4) Tufuling (Smilax glabra); (5) Shudahuang (cooked Radix et rhizoma rhei); (6) Cheqianzi (Semen plantaginis); (6) Donglingcao (Rabdosia rubescens); (7) Yumixu (Zea mays); (8) Bixie (Dioscoreae hypoglaucae); (9) Baihuasheshecao (Oldenlandia diffusa); (10) Xuanshen (Radix scrophulariae); and (11) Jinyinhua (Flos lonicerae). For proteinuria, drugs such as: (1) Jiangcan (Bombyx batryticatus); (2) Niubangzi (Fructus arctii); and (3) Huangshukuihua (Abelmoschus manihot) are commonly used[20-22]. Modern pharmacological research suggests that the major effects of herbal medicine are related to anti-inflammatory, antioxidative, antifibrotic and immunomodulatory pathways[6,12,23].

Most TCM practitioners consider that Qi and Yin deficiencies are the leading causes of IgAN and propose that the treatment of IgAN should be based on reinforcing Qi and replenishing Yin[24]. In contrast to the general TCM treatment, Professor Zou suggests that kidney deficiency is the most fundamental internal factor in the occurrence of IgAN and the treatment of IgAN should be based on tonifying the kidney and harmonizing other viscera. In addition, the spleen also plays an important role in the pathogenesis of IgAN. In TCM theory, the spleen governs the transportation and transformation of nutrients and water and it controls the function of spleen-qi to elevate food nutrients[17]. Tonifying the spleen is conducive to controlling proteinuria and improving metabolism. Recently, some powerful drugs, such as Leigongteng (Tripterygium wilfordii), have been proven to be protective against kidney diseases[25]. However, although these powerful drugs may have obvious short-term effects, they may easily hurt healthy Qi. Professor Zou advocates mild drugs to gradually dissipate the pathogenic factors without side effects. Unique academic thought and exquisite herbal selection reflect the power of Professor Zou as a National Chinese Medicine Master.

Herein, we report only one case, which has limited reference value to reflect Professor Zou’s treatment experience. However, we followed the patient for nearly 1 year and did not observe any subsequent disease relapse. Finally, 24-hour urine protein quantification is also an important laboratory indicator for IgAN, but we did not have access to these results because the patient did not undergo this test in the outpatient setting.