I. Introduction
Anemia refers to a reduction in the red blood cell component of peripheral venous blood and is clinically defined as a decrease in hemoglobin (Hb) concentration. According to the World Health Organization (WHO), anemia is diagnosed when Hb levels fall below 13.0 g/dL in adult men and 12.0 g/dL in adult women. Anemia is not regarded as a disease in itself but rather as a secondary manifestation of various underlying conditions. The causes are commonly divided into three groups which include impaired red blood cell production, increased red blood cell destruction known as hemolysis, and excessive loss of red blood cells through bleeding1.
Chronic kidney disease (CKD) is one of the most representative conditions that suppress red blood cell production. In CKD-related anemia, reduced erythropoietin synthesis and abnormalities in iron metabolism act in combination, leading to a decline in red blood cell formation2,3. Typically, anemia associated with CKD presents as normocytic or microcytic, but in some patients, macrocytic anemia may also occur due to factors such as vitamin B12 or folate deficiency, certain medications, or bone marrow dysfunction4.
Although less common, acute inflammatory diseases such as acute pancreatitis can also contribute to the development of anemia. Pancreatitis is often accompanied by systemic inflammatory response syndrome (SIRS), which may interfere with iron utilization, shorten red blood cell lifespan, and suppress hematopoiesis through acute-phase reactants5. In addition, gastrointestinal bleeding, infection, malabsorption, and nutritional deficiencies that may arise in the context of pancreatitis can further aggravate anemia6. In particular, when CKD and acute pancreatitis coexist, the process of identifying the underlying cause of anemia and formulating an appropriate treatment strategy becomes even more complex.
In Korean medicine, chronic diseases and acute inflammatory conditions that damage Qi and blood are recognized as patterns such as deficiency syndrome (虛證), blood deficiency (血虛), and kidney deficiency (腎虛). Treatment has traditionally focused on prescriptions that replenish Qi and blood while restoring the balance of Yin and Yang. Representative examples include Ginseng Yang-Young-Tang (人蔘養榮湯), Sipjeondaebo-Tang (十全大補湯), and Yukmijihwang-Tang (六味地黃湯), which are commonly used to improve symptoms such as dizziness, fatigue, and loss of appetite caused by Qi and blood deficiency. Their effectiveness has been reported in a variety of clinical cases7.
In the present case report, we describe a patient with macrocytic anemia suspected to have developed after an episode of acute pancreatitis in the context of chronic kidney disease. Korean medicine treatment was applied, and improvements were observed in both symptoms and overall quality of life.
II. Ethical Considerations
This case report is retrospective in nature and received an exemption from review by the Institutional Review Board (IRB) of Dongguk University Oriental Hospital (IRB File No. DUIOH 2025-08-012).
III. Case study
1. Sex and Age : Female, 78 years
2. Diagnoses
- G825 Quadriplegia
- N189 Chronic renal failure
- K8599 Acute pancreatitis
- D721 Eosinophilia
- L899 Pressure ulcer of the lower limb
3. Onset : Approximately 4 months prior to Korean medicine admission
4. Past Medical History
- Hypertension
- Septic shock
- Suspected acute cholecystitis and biliary pancreatitis
- Right retroperitoneal hematoma
- Dementia
- Deep vein thrombosis
- Pneumonia
5. Family History : None of significance
6. Present Illness The patient had a history of hypertension and chronic renal failure and had been on hemodialysis for approximately 9 years prior to Korean medicine admission. Approximately 5 months prior to Korean medicine admission, she experienced hypotension after dialysis and was admitted to the emergency department of a nearby university hospital. Since then, she received sequential treatment at several hospitals. Approximately 4 months prior to admission, she developed recurrent episodes of post-dialysis hypotension accompanied by coldness in the extremities. Approximately one month before Korean medicine admission, she was admitted to the emergency department of our hospital. During hospitalization, septic shock was suspected and she was treated with antibiotics including Meropenem and Vancomycin. After intensive care unit management, her vital signs stabilized and she was transferred to the general ward.
Approximately 1 month prior to Korean medicine admission, she developed vomiting after meals and fever. Abdominal CT and blood tests suggested acute cholecystitis and biliary pancreatitis, and she was admitted to the gastroenterology department of our hospital where she received antibiotic treatment. During this period, peripheral blood tests revealed macrocytic anemia. Since vitamin B12 and folate deficiency were not present, and considering her underlying chronic renal failure and gastrointestinal symptoms, the anemia was most likely secondary, associated with the inflammatory response and nutritional imbalance caused by acute pancreatitis.
As generalized weakness related to anemia persisted, it was determined that Korean medicine intervention was necessary to support overall recovery. Accordingly, she was admitted to the Department of Internal Korean Medicine.
7. Major Test Findings
1) Radiologic Examination : A chest X-ray performed at the time of admission showed no specific abnormalities. The noted findings were confirmed to have been present for more than one year. Therefore, no significant respiratory changes or clinical problems were identified, and follow-up observation was conducted (Fig. 1).
Fig. 2
Complete blood count and pancreatic enzyme tests.
Note : Day 1 represents the first day of hospitalization; Subsequent days are numbered sequentially.
Fig. 3
Inflammation marker.
Note : Day 1 represents the first day of hospitalization; Subsequent days are numbered sequentially.
Fig. 4
Kidney function test.
Note : Day 1 represents the first day of hospitalization; Subsequent days are numbered sequentially.
Fig. 5
Liver function test.
Note : Day 1 represents the first day of hospitalization; Subsequent days are numbered sequentially.
3) Peripheral Blood Morphology : Peripheral blood smear conducted on day 7 of hospitalization revealed macrocytic normochromic anemia. Mild red blood cell anisocytosis, toxic changes in neutrophils, and elevated eosinophils were observed. Platelet count and morphology were within the normal range.
4) Serum protein electrophoresis : The test performed on day 11 of hospitalization showed a decreased total protein level of 5.9 g/dL. Albumin fraction was reduced, while α1-, α2-, and γ-globulin fractions were elevated. No specific M-protein pattern was observed, suggesting an acute phase reaction related to inflammation.
8. Initial Findings
The patient was in a stuporous state with a decreased level of consciousness. Both pupils measured 2 mm in diameter, and direct as well as indirect light reflexes were normal. Manual muscle testing showed Grade 1 strength in both the left upper and lower limbs, Grade 3 in the right upper limb, and Grade 1 in the right lower limb. Muscle tone was evaluated as Grade 0 in the left upper and lower limbs, Grade 2 in the right upper limb, and Grade 3 in the right lower limb. The patient’s movements were severely restricted, making independent activities such as changing posture, controlling the head and trunk, sitting, standing, and walking impossible. Balance assessment revealed partial ability in both static and dynamic balance in sitting and standing positions, and the patient remained largely bedridden.
Neurological reflex examination revealed positive Babinski reflex bilaterally, negative Hoffman reflex, and positive ankle clonus on the left side. The patient produced sputum five to six times daily, usually expelled orally with coughing or straining. The sputum was yellow and viscous. Intermittent coughing and drooling were noted, but these improved with suctioning.
Sensory evaluation could not be performed for pain, temperature, touch, or proprioception due to poor cooperation. No evidence of dysphagia was observed. In language assessment, the patient exhibited no spontaneous speech, and abilities including comprehension, expression, naming, repetition, fluency, reading, and writing were all absent. Dysarthria was assessed as Grade 4.
9. Systemic Review
1) Sleep : approximately 20 hours of sleep per day
2) Appetite : average, taking three meals daily with New Care KD+ (250-250-300)
3) Urination : five times during the day, two to three times at night
4) Defecation : once every one to two days, normal stool
5) Fluid intake : average
6) Face : pale
7) Tongue : not observed due to lack of cooperation
8) Pulse (脈) : tight and rapid (緊數)
10. Treatment
1) Herbal Medicine : From the evening of day 1 of hospitalization to the morning of day 27 of hospitalization, the patient was prescribed Oryeong-san (五令散) 5 g in granule form (Korea Syntex Pharm. Co., Ltd.) three times daily. Beginning day 2 of hospitalization, in combination with W-med, Oryeong-san (五令散) 5 g (granules, Korea Syntex Pharm. Co., Ltd.) was additionally administered three times a day, one packet per dose. From lunch on day 27 of hospitalization until day 29 of hospitalization, Palmul-tang (八物湯) 3.59 g (Jeongwoo Herbal Medicine, mixed extract) was given three times daily, one packet each time. To further improve anemia and general weakness, the dosage of Palmul-tang (八物湯) was increased starting from the morning of day 30 of hospitalization until discharge on day 60 of hospitalization, with two packets administered three times daily. For the herbal composition of Oryeong-san (五令散) and Palmul-tang (八物湯), please refer to supplementary tables 1 and 2.
Table 1
The Component of Western Medicine
| Duration | Western medicine | Taking method |
|---|---|---|
| Day 1-Day 60 | Ascorbic Acid D.C. 61.86 mg, Cyanocobalamin 6 mg, Folic Acid 1000 ug, Nicotinamide 20 mg et al. | 1 T* qd** pc† |
|
|
||
| saccharomyces boulardii 282.5 mg | 1 pkg‡ bid§ pc | |
|
|
||
| Dioctahedral smectite 150 mg/mL | 1 pkg tid∥ pc | |
|
|
||
| Ursodeoxycholic Acid 200 mg | 1 T tid pc | |
|
|
||
| Milk-thistle Dried Ext. Powder 339.4 mg | 1 C¶ tid pc | |
|
|
||
| Day 6-Day 34 | potassium chloride powder 1 g | qd pc |
|
|
||
| Day 7 | Denosumab 60 mg | 1 syr†† |
|
|
||
| Day 1-Day 4 | sevelamer Carbonate 800 mg | 1 pkg tid w‡‡ |
|
|
|
|
| Day 5-Day 7 | 1 pkg bid w | |
|
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| Day 11-Day 12 | Propacetamol 1 g | 1 syr |
|
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||
|
Day 33-Day 36 Day 40-Day 42 Day 47-Day 50 Day 55-Day 57 |
Nacl powder 3 g | tid pc |
|
|
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| As needed | Amlodipine Besylate 13.888 mg (Post-dialysis on dialysis days; use if SBP≥160 mmHg) | 1 T qd pc |
Table 2
The Change of MMT
2) Acupuncture : During hospitalization, acupuncture was performed once daily for 15 minutes, with infrared irradiation applied concurrently during needle retention. The acupoints used were GV20 (百會), GB20 (風池), LI11 (曲池), LI4 (合谷), PC6 (內關), GB34 (陽陵泉), ST36 (足三里), SP9 (陰陵泉), GB39 (縣鍾), SP6 (三陰交), and LR3 (太衝). Stainless steel disposable needles (毫鍼, Dongbang Acupuncture Inc.) measuring 40 mm in length and 0.25 mm in diameter were used.
3) Western Medicine : During the admission period, the patient continued her previously prescribed medications. On day 6 of hospitalization, serum potassium was found to be 3.3 mmol/L, and potassium chloride powder 1 g was added for the management of hypokalemia. After potassium rose to 4.6 mmol/L on day 34 of hospitalization, the supplement was discontinued, although levels subsequently showed a tendency to decline again. On day 7 of hospitalization, denosumab (Prolia) injection was administered to treat hypocalcemia and osteoporosis. Between day 5 and day 6 of hospitalization, the dosage of Sevelamer carbonate (Renvela), which was being used to control hyperphosphatemia, was reduced from three times to twice daily as serum phosphate improved, and administration was discontinued from the evening of day 7 of hospitalization. On day 11 of hospitalization, the patient developed fever with a body temperature of 37.9 ℃, and Propacetamol 1 g (Denogan) injection was given for antipyretic purposes. Her temperature decreased to 37.1 ℃ within one hour. However, on day 12 of hospitalization, fever recurred with body temperature again rising to 37.9-38.0 ℃. The same dose of Propacetamol 1 g (Denogan) was administered, after which her temperature decreased to 37.3-37.6 ℃ (Table 1).
11. Evaluation Methods
1) Blood Tests : As the patient was undergoing hemodialysis, blood tests were conducted three times per week. These results were used to monitor overall trends and changes throughout the course of hospitalization.
2) Manual Muscle Test (MMT) : To objectively assess the muscle strength of the paralyzed upper and lower limbs, MMT was performed daily at 7:30 a.m. during the hospital stay. For the upper limbs, evaluations were based on shoulder flexion, elbow flexion, wrist extension, and finger flexion. For the lower limbs, assessments included hip flexion, knee extension, ankle dorsiflexion, and big toe extension. Each item was scored on a scale from 0 to 5, with 5 indicating normal muscle function and 0 indicating complete absence of muscle contraction. For detailed MMT Grade assessment methods, please refer to supplementary table 3.
12. Treatment Results
1) Blood Tests : On admission, blood tests showed hemoglobin (Hb) of 9.1 g/dL and hematocrit (Hct) of 26.9 percent, indicating anemia. Oryeong-san (五令散) was administered at this stage, but no remarkable improvement in anemia was observed. On day 28 of hospitalization, the prescription was switched to Palmul-tang (八物湯). Following this change, Hb levels gradually increased, reaching 11.0 g/dL at discharge on day 60 of hospitalization, while Hct rose to 33.9 percent. These findings reflected an overall reduction in the severity of anemia.
Regarding acute pancreatitis, serum amylase and lipase were elevated at admission, measured at 73 U/L and 282 U/L, respectively. Oryeong-san (五令散) was administered from the early stage of hospitalization. By day 11 of hospitalization, amylase and lipase had decreased to 57 U/L and 207 U/L, but a transient increase was noted on day 19 of hospitalization, reaching 72 U/L and 281 U/L. As the patient did not exhibit abnormal symptoms such as vomiting, nausea, or fever, the values were monitored without further intervention. After switching to Palmul-tang (八物湯) on day 28 of hospitalization, the values steadily improved, and at discharge on day 60 of hospitalization, amylase was 47 U/L and lipase was 97 U/L. These results suggest resolution of pancreatic inflammation and stabilization of pancreatic function (Fig. 2).
During hospitalization, fever developed due to pneumonia, accompanied by temporary increases in white blood cell (WBC) count, neutrophils, absolute neutrophil count (ANC), and C-reactive protein (CRP). With clinical improvement and resolution of fever, WBC decreased from 8.19×10³/μL at admission to 6.62×10³/μL at discharge, ANC declined from 3,071 to 2,878, and CRP decreased from 4.25 to 0.89. Although the proportion of neutrophils rose slightly from 37.5 percent to 42.1 percent, this was interpreted as a relative percentage change rather than a pathological increase.
Although CRP transiently rose to 4.85 following pneumonia development, the patient remained asymptomatic. WBC was 5.07×10³/μL, ANC declined to 1,957, and neutrophils were 38.6 percent, all within normal limits. Subsequently, CRP decreased to 2.5 and continued to decline through the final laboratory assessment (Fig. 3). Electrolyte fluctuations were also noted during the hospital stay. In the early stage, potassium chloride supplementation was given for hypokalemia, while later in the course sodium chloride powder was administered for hyponatremia (Table 1).
Throughout the period of herbal treatment, serial blood tests confirmed gradual improvement in major indicators including Hb, Hct, amylase, and lipase. These findings suggest that Korean medicine treatment, particularly Palmul-tang (八物湯), may have contributed as a supportive intervention. Furthermore, no significant abnormalities were detected before or after treatment in other parameters such as electrolytes, renal function (eGFR, creatinine), or liver function (AST, ALT, albumin), providing indirect evidence for the safety of the herbal prescriptions used (Fig. 2, 3, 4, 5).
2) Manual Muscle Test (MMT) : On admission, the patient presented with quadriplegia, with both upper and lower limbs graded at MMT Grade 1. During the course of treatment, gradual improvement in muscle strength was observed. From day 36 of hospitalization, recovery began in the upper limbs, reaching Grade 3, at which level joint movement against gravity was possible. By day 46 of hospitalization, further progress was noted, with the upper limbs achieving Grade 3+, indicating movement against slight resistance. At this stage, the lower limbs remained at Grade 1. However, continued treatment led to gradual recovery in the lower limbs as well, and eventually both upper and lower limbs reached Grade 3+. These findings demonstrate that improvement was initially evident in the upper limbs, but over time a similar pattern of recovery was also achieved in the lower limbs (Table 2).
IV. Discussion
The patient in this case was an elderly woman with chronic renal failure on hemodialysis for approximately 9 years. Approximately 4 months prior to Korean medicine admission, she experienced duodenal ulcer bleeding requiring transfusion and hemostasis. Approximately 2 months prior to admission, she developed acute cholecystitis and pancreatitis, which further exacerbated chronic anemia (Hb 8-9 g/dL). Laboratory findings on day 11 of hospitalization revealed signs of inflammation and nutritional imbalance. Despite vitamin B complex supplementation, macrocytic anemia persisted, and no improvement was achieved with initial Oryeong-san (五令散) treatment.
The patient’s anemia resulted from multiple overlapping factors including chronic renal failure, acute pancreatitis, recurrent gastrointestinal bleeding, infection, and nutritional imbalance. After switching to Palmul-tang (八物湯), hemoglobin levels gradually increased from 9.1 g/dL to 11.0 g/dL at discharge without additional transfusions or new medications. Thrice-weekly blood tests confirmed objective improvement in hematologic parameters, and no deterioration in liver or kidney function was observed during treatment.
The improvement with Palmul-tang (八物湯) can be explained through several mechanisms supported by existing research. Palmul-tang (八物湯), traditionally used for blood deficiency (血虛), has been shown in previous studies to enhance hematopoietic progenitor cell proliferation and promote erythrocyte production through upregulation of erythropoietin-related pathways8,9. The formula’s anti-inflammatory properties, documented to reduce pro-inflammatory cytokines (TNF-α, IL-6, IL-1β), likely mitigated the acute-phase response from pancreatitis and pneumonia that typically suppresses red blood cell production10. Additionally, the herbal components contain bioavailable micronutrients and polysaccharides that enhance intestinal absorption and support erythropoiesis despite the patient’s compromised gastrointestinal function11.
Although Oryeong-san (五令散) showed no immediate hematologic benefit, research demonstrates its anti-inflammatory and organ-protective properties may have contributed to disease stabilization12,13. The transition to Palmul-tang (八物湯) appears to have been the critical therapeutic decision, as improvements in serum protein electrophoresis (albumin normalization, reduction of acute-phase globulins) and sustained reduction in inflammatory markers (CRP, amylase, lipase) support the hypothesis that the formula addressed underlying pathophysiologic mechanisms.
In addition to hematologic improvement, the patient demonstrated functional recovery with manual muscle testing showing progression from Grade 1 to Grade 3+ in upper limbs and eventual Grade 3+ in lower limbs. This suggests that Korean medicine treatment enhanced not only anemia correction but also overall physical capacity and quality of life. The improvement in functional capacity may be attributed both to enhanced oxygen-carrying capacity from anemia correction and to the formula’s documented effects on blood circulation and constitutional strength.
Previous reports in the literature have described cases in which anemia associated with conditions such as alcoholic hepatitis or vitamin B12 deficiency improved following Korean medicine treatment14-16. What distinguishes this case is that the patient presented with a complex background of chronic kidney disease (CKD) and acute pancreatitis, compounded by recurrent bleeding and infection, yet demonstrated improvement in anemia. This case represents an extension of existing research by demonstrating that blood-tonifying formulas such as Palmul-tang (八物湯) can be effective in complex, multifactorial anemia associated with CKD and acute inflammatory disease. The sustained improvement without additional hematinics suggests that Palmul-tang (八物湯) addressed underlying pathophysiologic mechanisms rather than providing symptomatic support alone.
Therefore, this case provides clinical evidence supporting the therapeutic application of Palmul-tang (八物湯) in elderly patients with CKD-related anemia complicated by acute inflammation. Future comparative studies and mechanistic investigations in CKD-related anemia would further elucidate the pathways by which these herbal formulas exert therapeutic effects. Long-term collaborative research combining Western and Korean medicine approaches will be needed to establish evidence-based protocols and improve outcomes in elderly patients with chronic diseases.
V. Conclusion
This case demonstrates that Palmul-tang (八物湯), a traditional blood-tonifying herbal formula, can effectively improve macrocytic anemia in an elderly patient with the complex conditions of chronic kidney disease and acute pancreatitis. The patient achieved significant improvements in hemoglobin levels (9.1 to 11.0 g/dL) and functional capacity without additional transfusions or new medications, supported by objective laboratory findings and safety monitoring. These results provide clinical evidence for mechanisms previously described in research on blood-tonifying formulas, including anti-inflammatory effects, enhancement of hematopoiesis, and improved nutritional support. Although this is a single case report with inherent limitations, it extends the existing evidence base by demonstrating that herbal formulas such as Palmul-tang may play a meaningful role in managing multifactorial anemia in elderly patients with chronic kidney disease. Future comparative studies and mechanistic investigations would strengthen the evidence for incorporating Korean medicine approaches into comprehensive CKD management strategies and improving quality of life in elderly patients with chronic diseases.
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