Comparative Clinical Evaluation of Boerhavia Diffusa Root Extract With Standard Enalapril Treatment in Canine Chronic Renal Failure

2/25/23, 11:07 AM Comparative clinical evaluation of Boerhavia diffusa root extract with standard Enalapril treatment in Canine chronic
chronic renal fai…
J Ayurveda Integr Med. 2015 Jul-Sep; 6(3): 150–157. PMCID: PMC4630688

doi: 10.4103/0975-9476.166390 PMID: 26604549
Comparative clinical evaluation of Boerhavia diffusa root extract with standard

Enalapril treatment in Canine chronic renal failure
Nethaji Lokeswar Oburai,1 V. Vaikunta Rao,2 and Ram Babu Naik Bonath3
Abstract
Background:
Complementing herbal drugs with conservative modern treatment could improve renal condi‐
tion in canine chronic renal failure (CRF).
Objective:
In this study, clinical evaluation of Boerhavia diffusa root extract was carried out in CRF in dogs
in comparison with standard enalapril.
Materials and Methods:
A total of 20 dogs of mixed breeds suffering from CRF from 1 to 2 months were divided into
two groups (n = 10) and treated as follows: Group I - Enalapril at 0.5 mg/kg p.o. once daily for
90 days + amoxicillin and cloxacillin at 25 mg/kg i.m. once daily for 1-week; Group II - B. diffusa
root extract at 500 mg p.o per dog daily for 90 days. Both groups were maintained on a sup‐
portive fluid therapy. The data were analyzed using paired t-test and one-way ANOVA followed
by Dunnett's post-hoc test.
Results:
CRF caused a significant (P < 0.05) increase in systolic and diastolic blood pressure, serum cre‐
atinine, urea nitrogen, sodium, potassium, phosphorus, urinary protein, alkaline phosphatase
(ALP), and glutamyl transferase (GGT). A significant (P < 0.05) decrease in hemoglobin and to‐
tal erythrocyte count (TEC) was also observed. Nephrosonography revealed indistinct corti‐
comedullary junction, altered renal architecture, hyper-echoic cortex, medulla, and sunken kid‐
neys. Both the treatments significantly (P < 0.05) reduced systolic and diastolic blood pressure
by day 30. Serum Creatinine, urea nitrogen, phosphorus, urinary protein, ALP, and GGT
showed significant (P < 0.05) reduction by day 60 in both the treatments. However, potassium
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4630688/ 1/14
2/25/23, 11:07 AM Comparative clinical evaluation of Boerhavia diffusa root extract with standard Enalapril treatment in Canine chronic renal fai…
levels were normalized only by B. diffusa root extract treatment by day 30. Both the treatments
failed to show a significant improvement in nephrosonographic picture even after 90 days
posttreatment.
Conclusion:
In conclusion, the efficacy of B. diffusa root extract was comparable to standard enalapril treat‐
ment of CRF in dogs.
Keywords: Boerhavia diffusa, chronic renal failure, dogs, enalapril, nephrosonography
INTRODUCTION
Chronic renal failure (CRF) or chronic kidney disease is a common kidney disease in dogs with
a prevalence of 0.05–3.74%. The risk factors for CRF include old age, specific breeds, smaller
body size, periodontal disease, and obesity.[1] Standard therapy for CRF is aimed at the man‐
agement of proteinuria, inhibition of renin-angiotensin-aldosterone system, correcting fluid
balance, and hypertension.[2] But with the progression of CRF to end-stage disease, renal
function can be regenerated only by kidney transplantation or dialysis, which is costlier and
unaffordable in veterinary cases. Hence, Ayurvedic drugs can be used to complement modern
medicines to reverse kidney damage in animals.[3]
Herbs are increasingly becoming popular for the treatment of various diseases in both human
and veterinary practice. Several instances of medicinal properties of plants and plant products
are well-documented in animal models such as anti-hyperlipidemic activity,[4] anti-diabetic ac‐
tivity,[5] protective activity against toxicities produced by mycotoxins,[6] pesticides,[7] and
heavy metals.[8] Further, several plant products are found to be safe through safety assess‐
ment as per OECD guidelines.[9,10,11] Recently, phytochemicals are being used for the synthe‐
sis of nanoparticles, which are effective and safe in several diseases.[12,13]
Boerhavia diffusa (Family: Nyctaginaceae) is commonly known as Raktapunarnava, Shothaghni,

Kathillaka, Kshudra, Varshabhu, Raktapushpa, Varshaketu, and Shilatika.[14,15] The plant is
also called “Punarnava,” due to its ability to regenerate in rainy season with the help of peren‐
nial roots after the aerial parts get dried up completely in summer.[16] In Ayurveda, the plant
is considered to be light (Laghu), dry (Ruksha) and hot potency (Ushna veerya) and the prop‐
erties like: Rasa-Madhura, Tikta, Kashaya; Veerya-Ushana; Vipaka-Madhura and Karma-
Anulomana, Shothahara and is considered to alleviate all three doshas.[17]
The roots of B. diffusa contain many rotenoids.[18,19,20,21] Further, it also has

Punarnavoside, a phenolic glycoside,[22,23] C-methyl flavone[24] and 6.0% potassium nitrate,
and ursolic acids.[25] B. diffusa was reported to offer significant protection against kidney
disease[26] and urolithiasis.[27] The regenerative effects of B. diffusa on kidneys is also re‐
ported.[28] However, the therapeutic efficacy of root extract of B. diffusa for the treatment of
CRF is not extensively studied in veterinary cases. Hence, this study was aimed at investigating
nephroprotective effect of B. diffusa for the treatment of CRF in dogs in comparison with mod‐
ern conservative treatment.
MATERIALS AND METHODS
Chemicals used
Boerhavia root hydro-alcoholic extract (Himalaya Punarnava-Himalaya Drug Company, India;

containing 250 mg hydro-alcoholic extract per capsule), enalapril (Canvas 5 mg-Zydus Cadila,
India); ampicillin and cloxacillin (Novaclox 1 g-Cipla, India), metaclopramide (Perinorm 5
mg/mL-IPCA Laboratories Ltd., India); ranitidine (Aciloc 50 mg/mL-Cadila Pharmaceuticals,
India), Ringer's lactate (Basol Infusion-Cadila Pharmaceuticals, India); B-complex (Polybion-
Merck, India) were used in the study.
Animals used
Dogs belonging to the breeds Spitz, German Shepard, Labrador Retriever, Great Dane,
Doberman pinscher and mongrels of both sexes aged between 8 and 12 years of age suffering
from renal failure were included in the study. Healthy dogs of Animal Care Land, Tirupati were
used as controls.
Clinical cases
Dogs presented to the Teaching Veterinary Clinical Complex of the College with clinical and
nephrosonographic changes suggestive of CRF, serum creatinine between 3.0 and 5.0 mg/dL
and without anemia or ascites from 1 to 2 months were included in the study. Institutional
Animal Ethic Committee approval was obtained prior to the start of the study. A total of 20
dogs with the above criteria were randomly divided into two treatment groups. Group I dogs
were treated with enalapril at 0.5 mg/kg p.o once daily for 90 days + amoxicillin and cloxacillin
at 25 mg/kg i.m once daily for 1-week; Group II dogs were treated with B. diffusa root extract
at 500 mg per animal p.o, once daily for 90 days. Both the groups were maintained on a sup‐
portive therapy consisting of ringer's lactate infusion at 30 mL/kg i.v., once daily for correcting
electrolyte imbalance; metoclopramide at 0.2 mg/kg i.m., once daily for preventing uremia-in‐
duced-vomition; ranitidine at 2 mg/kg i.m., once daily as H2-antagonist for decreasing gastric
acid production and B-complex at 1 mL/dog i.m., once daily for improving status of water-solu‐
ble B-vitamins. The owners were advised to provide low salt and low protein diet and to in‐
crease energy density of the feed. Both the treatment groups were compared with 10 appar‐
ently healthy dogs of different breeds aged 3–5 years.
Detailed history, clinical observations, blood pressure monitoring, serum biochemical profile,
urinalysis, and nephrosonography were carried out at monthly interval up to 3 months.
Blood pressure monitoring
For measuring blood pressure, human wrist model automatic oscillometric sphygmomanome‐
ter (BPL Ltd., India) was used. The dog was positioned in sternal recumbency, and the cuff was
placed on the left forelimb region. The transducer was positioned on the medial aspect of the
arm over the median artery, and the Velcro was wrapped around the foreleg [Figure 1]. The
average of five consecutive readings was taken as the blood pressure.
Figure 1
Placement of sphygmomanometer on the left forelimb of dog in sternal recumbency
Sero-biochemical profile
Serum was obtained from 3 mL of blood collected from saphenous vein and parameters such
as creatinine, urea nitrogen, total protein, sodium, potassium, calcium, phosphorus were ana‐
lyzed using standard kits supplied by span diagnostics Ltd., Surat using star 21 semi-auto bio‐
chemistry analyzer (Rapid Diagnostic Pvt., Ltd., Delhi)
Urinalysis
Five milliliters of mid-stream or cystecentesized urine was collected and urine pH, specific
gravity, and protein were determined using URISCAN dip sticks. Later, the urine was cen‐
trifuged at 1500 rpm for 5 min, and the sediment was examined for casts, pus cells, and other
sediments. Alkaline phosphatase (ALP) and gamma glutamyl transferase (GGT) were estimated
from the supernatant urine using standard kits supplied by Accurex Biomedical Pvt., Ltd,
Mumbai.
Nephrosonography
The hair on the abdomen was shaved midway up to the body wall over the right and left caudal
intercostal spaces. Nephrosonography was performed in either dorsal or sternal recumbency
using IXOS vet-ultrasound machine supplied by Esoate Pie Medical, Netherlands. A linear array
of 3.5, 5.0, and 7.5 mHz probes were used for small, medium, or large dogs, respectively. The
left kidney was imaged caudal to the greater curvature of the stomach, caudo-dorsal to the
spleen, later to the aorta, and left adrenal gland at the level of L2– L4 vertebrae. The right kid‐
ney was imaged caudal to right liver lobes, lateral to the caudal vena cava and right adrenal
gland at the level of L1–L3 vertebrae.[29]
Sonograms were evaluated for information on renal architecture specifically including focal,
multifocal of diffuse alterations in renal cortical, medullary, sinusal, and peripheral echogenic‐
ity. In addition, cortical and medullary echogenicity were compared subjectively with hepatic
and splenic parenchymal echogenicity. The echogenicity of the identifiable lesion, as seen on
the gray scale two-dimensional images were classified subjectively as normal, increased (hy‐
perechoic), decreased (hypoechoic), and absent compared to normal echo pattern for canine
kidney.[30]
Statistical analysis
The data for various parameters were expressed as mean ± standard error. In both the
groups, after treatment values at different time intervals (30, 60, and 90 days) were compared
with before treatment values (0 day) using paired t-test. Similarly, the control values were com‐
pared with different time periods (0, 30, 60, and 90 days) using one-way ANOVA followed by
Dunnett's post-hoc test using Statistical package for social sciences(SPSS) 19.0V (IBM SPSS, v
19.0, Armonk, NY). The level of significance was set at P < 0.05.
RESULTS
The predominant symptoms in CRF dogs were anorexia, vomiting, dullness, weight loss, oral ul‐
cers and in few cases polydypsia, pale mucosa, recumbency, and blindness were also observed
before treatment. A significant (P < 0.05) increase in both systolic and diastolic arterial pres‐
sure was observed in CRF affected dogs compared to control. Treatments with enalapril in
Group I and B. diffusa root extract in Group II significantly (P < 0.05) reduced both systolic and
diastolic blood pressure by day 30 and were comparable to control dogs [Table 1].
Table 1
Mean blood pressure in treatment groups at various time intervals
The hemoglobin (Hb) and total erythrocyte concentrations (TEC) in CRF dogs were signifi‐
cantly (P < 0.05) decreased compared to control dogs. Both enalapril and B. diffusa root ex‐
tract treatment could significantly (P < 0.05) increase Hb levels by day 60; however, only in B.
diffusa root extract treatment, the Hb values were comparable to normal by day 90. Both treat‐
ments failed to show any significant improvement in TEC even after 90 days posttreatment [
Table 2].
Table 2
Mean hematological parameters in treatment groups at various time intervals
In CRF affected dogs, a significant (P < 0.05) elevation of serum creatinine, urea nitrogen, total
protein, albumin, and phosphorus levels compared to control group before treatment. The
urine of CRF dogs revealed casts, epithelial cells, red blood cells in the sediment. A significant
(P < 0.05) decrease in specific gravity and a significant (P < 0.05) increase in urinary protein [
Figure 2], ALP, and GGT were also elevated compared to control dogs on day 0. Both the treat‐
ments significantly (P < 0.05) decreased serum creatinine, urea nitrogen, urinary protein [
Figure 2], and urine ALP and GGT by day 60. However, potassium [Figure 3] and phosphorus
levels showed significant (P < 0.05) reduction by day 30 only in B. diffusa root extract treat‐
ment. Enalapril treatment could significantly (P < 0.05) reduce only phosphorus level by day
60 [Tables 3 and 4] but failed to improve potassium level.
Figure 2
Urinary protein levels in control and treatment groups. Boerhavia diffusa extract could normalize urinary pro‐
tein by day 90, whereas, no improvement was observed in conventional treatment. Std.: Standard, C: Control,
T: Treatment. *Significant (P < 0.05) difference with control group
Figure 3
Serum potassium levels in control and treatment groups. Boerhavia diffusa could normalize serum potassium
level by day 30, whereas, no improvement was observed in conventional treatment. Std.: Standard, C: Control,
T: Treatment. *Significant (P < 0.05) difference with control group
Table 3
Serum biochemical profile in treatment groups at various time intervals
Table 4
Urinalysis in treatment groups at various time intervals
Nephrosonography of normal dogs revealed that the renal cortical echogenicity of the left kid‐
ney was less than adjacent spleen; right kidney cortical echogenicity was less than the adjacent
liver [Figure 4]. The medulla was hypoechoic, round with well-defined corticomedullary junc‐
tion [Figure 5]. Pelvis was hyperechoic. In dogs affected with CRF, the cortex was hyperechoic
with indistinct corticomedullary junction [Figure 6], altered renal architecture, and sunken kid‐
neys [Figure 7]. However, both the treatments failed to show significant improvement in
nephrosonogram even after 90 days of treatment.
Figure 4
Nephrosonogram showing normal kidney in control dogs
Figure 5
Nephrosonogram showing hyperechoic medulla without clear corticomedullary junction in dogs with
chronic renal failure
Figure 6
Nephrosonogram showing hyperechoic cortex without clear corticomedullary junction in dogs with chronic
renal failure
Figure 7
Nephrosonogram showing shrunken kidney in dogs with chronic renal failure
DISCUSSION
CRF is an important clinical condition in dogs which results from reduced renal function and to
impaired homeostasis. As the clinical signs of CRF are nonspecific, many cases go unnoticed in
veterinary practice. The treatment of CRF is also an economic constraint for the owner. The
predominant clinical signs in CRF dogs were anorexia, vomiting, dullness, weight loss, oral ul‐
cers, polyuria, polydipsia, pallor of mucous membrane, melena, recumbency, and blindness.
These signs are consistent with earlier findings.[31,32,33] Renal dysfunction leads to uremia,
which stimulates chemoreceptor trigger zone, resulting in anorexia and vomition.[34] Weight
loss and dullness are directly linked to inadequate calorie intake, catabolic effects of uremia,
and intestinal malabsorption secondary to uremic gastroenteritis.[35] Pallor mucous mem‐
brane due to anemia, a characteristic symptom of advanced CRF, results from decreased ery‐
thropoietin production by damaged kidneys.[36]
In this study, the clinical cases showed the signs of improvement between 15 and 30 days of
treatment in both the groups. Conservative therapy of CRF dogs consisted of symptomatic and
supportive therapy designed to correct the deficiencies and excess in fluids, electrolytes, acid-
base, and nutritional imbalances and thereby minimizing the clinical and pathological conse‐
quences of reduced renal function.[2] After 90 days of treatment, moderate improvement in
appetite, body weight gain and improvement in behavior in survived dogs were noticed in both
the groups. However, five dogs in enalapril treatment and two dogs in B. diffusa treatment died
between 60 and 90 days posttreatment.
Systolic arterial and diastolic arterial pressure showed a significant (P < 0.05) increase in CRF
dogs compared to healthy dogs.[37,38,39] Both the treatments significantly (P < 0.05) de‐
creased the systolic and diastolic arterial pressure by day 30. Enalapril, an angiotensin con‐
verting enzyme inhibitor, is reported to possess anti-hypertensive activity and was earlier used
successfully in several cases of CRF in dogs.[40,41,42] The anti-hypertensive activity of B. dif‐
fusa root extract can be attributed to punarnavoside component, which was reported to pos‐
sess anti-hypertensive property.[43] The root extract of B. diffusa was successfully used by
ayurvedic practitioners for management of CRF in human beings.[44,45]
In CRF, about 2/3 of the nephrons in kidney are damaged, which results in decreased water
conservation and loss of several important susbtances.[46] In this study, the mean values of
serum urea nitrogen, creatinine, sodium, and phosphorous were significantly (P < 0.05) ele‐
vated in CRF dogs compared to control.[34,47,48,49] The raised serum urea nitrogen and cre‐
atinine levels in CRF dogs could be due to retention of nitrogenous substances[48,50] due to
reduced glomerular filtration rate and decreased excretory rate of kidneys.[48,50,51] In addi‐
tion, gastrointestinal hemorrhages also contribute to increased urea nitrogen due to enhanced
absorption of nitrogenous compounds.[56] Enalapril treatment significantly (P < 0.05) de‐
creased urea nitrogen, creatinine, sodium, and phosphorus levels by day 60 compared to day
0. However, enalapril treatment failed to improve serum potassium level even after 90 days of
treatment. This indicated stable renal function and delayed progression of the renal disease by
enalapril treatment.[55] Similar reduction results were seen with B. diffusa root extract treat‐
ment except that earlier response (by day 30) in terms of significantly (P < 0.05) decreased
urea nitrogen and phosphorus was observed. Further, the decreased potassium levels were re‐
stored to normal by day 30 in B. diffusa root extract treatment, which can be attributed to the
potassium nitrate content (6%) in B. diffusa root extract.[43] Similarly, the elevated sodium lev‐
els in CRF was significantly (P < 0.05) decreased by day 60 in B. diffusa treatment consequent
to improved renal function. B. diffusa has a diuretic effect similar to furosemide, a potent loop
diuretic[26] and is responsible for the enhanced elimination of metabolic wastes.[43,57]
The total protein and albumin levels showed no significant change in CRF dogs compared to
control dogs. This is possibly due to improved appetite and decreased catabolic effects by
virtue of the partial restoration of renal function and anti-proteinuric effect of
enalapril[53,54,55] and B. diffusa.[43] However, earlier works[47] observed hypoproteinemia
and hypoalbuminemia in CRF dogs and attributed the loss of albumin through glomeruli, ow‐
ing to its small size, as the possible explanation.[52]
Elevated markers enzymes such as ALP and GGT are indicative of renal damage.[58,59] In CRF,
as a consequence of kidney damage, the concentrating ability of the kidney is lost leading to
polyuria and decreased specific gravity of urine.[34] Similarly, glomerular damage results in in‐
creased urinary protein excretion.[50] The reduction in urinary protein excretion could be at‐
tributed to the anti-proteinuric effect of enalapril[54,55] and diuretic action of B. diffusa in
treatment Group II.[26,60]
The ultrasonographic changes in CRF revealed hyperechoic cortex, indistinct corticomedullary

junction, and hyperechoic medulla. Several authors reported overall increase in echogenicity
(hyperechoic) and reduced corticomedullary definitions in dogs with chronic inflammatory
and end-stage renal diseases.[30,61,62,63] The deposition of calcium in renal cortex is possi‐
ble the explanation for increased echogenicity.[61]
CRF is a serious progressive and irreversible disease usually seen in older dogs with poor
prognosis. Between day 60 and 90, five dogs in enalapril group and two dogs in B. diffusa
group died despite good compliance from the owners. Conservative therapy with enalapril to
control hypertension and ampicillin + cloxacillin to prevent urinary infections showed clinical
improvement; however, treatment with B. diffusa could improve the overall survivability and
recovery in CRF dogs.
As B. diffusa is a promising alternative treatment modality in CRF, studies addressing the phar‐
macokinetics of B. diffusa extract, especially in renal failure, are necessary for determining opti‐
mum dosage in CRF dogs. Further, including a biopsy examination of kidneys, before and after
the therapy, can reveal nephron rejuvenating abilities of the plant, if any.
CONCLUSION
The beneficial effect of conservative treatment with enalapril to manage CRF in dogs is well-
documented.[41,63,64,65] Outcomes with B. diffusa root extract treatment were comparable to
enalapril. The advantages of B. diffusa were faster improvement in most outcome variables like
Hb, potassium, phosphorus by day 30 and urinary protein by day 90, and a greater increase in
serum potassium in CRF dogs. Also, it must be noted that five CRF dogs in the enalpril group
and only two CRF dogs in Punarnava group died between 60 days and 90 days posttreatment.
Further, the improvement of several clinical parameters was much earlier in B. diffusa root ex‐
tract treatment.
Footnotes
Source of Support: Sri Venkateswara Veterinary University, Tirupati
Conflict of Interest: None declared.

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Comparative Clinical Evaluation of Boerhavia Diffusa Root Extract With Standard Enalapril Treatment in Canine Chronic Renal Failure

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Comparative Clinical Evaluation of Boerhavia Diffusa Root Extract With Standard Enalapril Treatment in Canine Chronic Renal Failure

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2/25/23, 11:07 AM Comparative clinical evaluation of Boerhavia diffusa root extract with standard Enalapril treatment in Canine chronic

chronic renal fai…

J Ayurveda Integr Med. 2015 Jul-Sep; 6(3): 150–157. PMCID: PMC4630688

Comparative clinical evaluation of Boerhavia diffusa root extract with standard

Materials and Methods:

Keywords: Boerhavia diffusa, chronic renal failure, dogs, enalapril, nephrosonography

Boerhavia diffusa (Family: Nyctaginaceae) is commonly known as Raktapunarnava, Shothaghni,

The roots of B. diffusa contain many rotenoids.[18,19,20,21] Further, it also has

MATERIALS AND METHODS

Boerhavia root hydro-alcoholic extract (Himalaya Punarnava-Himalaya Drug Company, India;

Blood pressure monitoring

Placement of sphygmomanometer on the left forelimb of dog in sternal recumbency

Mean blood pressure in treatment groups at various time intervals

Mean hematological parameters in treatment groups at various time intervals

Serum biochemical profile in treatment groups at various time intervals

Urinalysis in treatment groups at various time intervals

Nephrosonogram showing normal kidney in control dogs

Nephrosonogram showing shrunken kidney in dogs with chronic renal failure

The ultrasonographic changes in CRF revealed hyperechoic cortex, indistinct corticomedullary

Source of Support: Sri Venkateswara Veterinary University, Tirupati

Conflict of Interest: None declared.

39. Buranakarl C, Ankanaporn K, Thammacharoen S, Trisiriroj M, Maleeratmongkol T, Thongchai P, et al. Relationships

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