Chronic kidney disease (CKD) is characterized by the presence of structural or functional abnormalities of the kidneys, or a sustained reduction in renal function, as indicated by an estimated glomerular filtration rate (eGFR) below 60 mL/min/1.73 m², lasting for at least three months, regardless of underlying etiology¹. Globally, the burden of CKD continues to increase, largely driven by the rising prevalence of hypertension and diabetes, with an estimated worldwide prevalence of 9.1% in 2017, underscoring the importance of prevention, early identification, and timely management to reduce CKD-related complications². Therefore, the prevalence of end-stage renal disease is higher than that reported in comparable settings, with diabetes and hypertension identified as the predominant underlying conditions, highlighting the potential role of early detection, optimal control of blood pressure and glycemia, and primary preventive strategies in reducing disease progression and overall burden³.

Bojungikgi-tang is a classical Korean herbal formula first documented in 1232 AD in Dongwon’s Ten Medical Texts. The formulation comprises Astragali Radix, Ginseng Radix, Atractylodis Rhizoma Alba, Glycyrrhizae Radix et Rhizoma, Angelicae Gigantis Radix, Citri Unshius Pericarpium, Cimicifugae Rhizoma, and Bupleuri Radix. The name of the prescription, commonly interpreted as “supplementing the center and augmenting qi,” reflects its traditional indication for clinical presentations involving gastrointestinal dysfunction and generalized weakness. Bojungikgi-tang has been widely used in East Asian medical practice and continues to be administered in contemporary settings, including standardized granule formulations⁴. In clinical practice, Bojungikgi-tang has been administered to patients presenting with fatigue, reduced functional status, or immune-related vulnerability, particularly in the context of chronic disease or prolonged illness. In an animal safety evaluation, repeated oral administration of Bojungikgi-tang in male rats was not associated with adverse clinical signs, pathological findings, or clinically meaningful changes in renal weight, serum renal markers, or histology, suggesting no evidence of renal toxicity under the study conditions⁵.

In this case report, we describe a patient with stage 5 CKD and confirmed vancomycin-resistant enterococci (VRE) colonization who received Korean medicine-based treatments during hospitalization. Clinical symptoms and serial laboratory parameters were monitored at least weekly and demonstrated temporal changes over the course of care; notably, follow-up testing showed clearance of VRE colonization, which has clinical relevance given the associated infection control considerations.

This study is a retrospective case report conducted in compliance with the CARE guidelines and was approved by the Institutional Review Board of Kyung Hee University Korean Medicine Hospital (IRB File No. 2026-02-008).

1. Sex and Age : Female, 84 years

2. Diagnosis

1) N185 Chronic kidney disease stage 5 history of urosepsis

2) N390 Urinary tract infection

3) I129 Hypertensive renal disease

4) Vancomycin Resistant Enterococci (+)

3. Onset : 2024.7.24

4. Past medical history

1) Diabetes Mellitus type 2

2) Hypertension

3) Dyslipidemia

4) ACOS (Asthma-COPD Overlap Syndrome)

5) Hypothyroidism

6) Internal carotid artery (ICA) stenosis

7) Alzheimer’s disease

5. Family History

1) Diabetes Mellitus

2) Hypothyroidism

6. Present illness

The patient with CKD and multiple comorbidities presented with progressive nausea, vomiting, dyspnea, and generalized weakness. Her medical history included diabetes mellitus, hypertension, dyslipidemia, asthma-COPD overlap syndrome, and a previous episode of urosepsis. In July 2024, she visited the emergency department with cough and sputum production and was diagnosed with viral pneumonia complicated by acute kidney injury superimposed on CKD. She was hospitalized from July 24 to August 3, 2024, received conservative management, and was discharged with improvement in renal function. On January 31, 2025, she re-presented with persistent gastrointestinal symptoms and dyspnea. Laboratory evaluation revealed hyperkalemia and elevated serum creatinine levels. She was admitted on the same day, and her estimated glomerular filtration rate was 13 mL/min/1.73 m² on February 1, 2025, consistent with CKD stage 5. Hemodialysis was initiated on February 3, 2025, resulting in partial symptom relief. Despite maintenance hemodialysis three times weekly, she subsequently experienced rapid weight loss accompanied by worsening fatigue and bilateral lower extremity weakness. Due to progressive functional decline, she was transferred on March 5, 2025, to the Kyung Hee University Korean Medicine Hospital for integrative treatment (Fig. 1).

7. Major test findings

1) Radiologic examination: A chest radiograph obtained on admission revealed no active lung lesion or remarkable abnormalities. The observed findings were confirmed to have been unchanged for over a year. Accordingly, no clinically meaningful respiratory deterioration was identified, and further follow-up showed identical results.

2) ECG : An electrocardiogram was obtained on admission and after discharge, and both examinations revealed normal sinus rhythm without clinically significant abnormalities.

3) Blood tests: Laboratory evaluation revealed anemia, with a hemoglobin level of 8.9 g/dL and a hematocrit of 27.7%. The white blood cell count (5.04×10³/µL) and absolute neutrophil count (3,019 cells/µL) were within normal limits. In contrast, inflammatory markers were markedly elevated, with an erythrocyte sedimentation rate of 120 mm/hr and a C-reactive protein level of 5.35 mg/dL. Renal function tests demonstrated elevated blood urea nitrogen (25 mg/dL) and serum creatinine (4.77 mg/dL), corresponding to an estimated glomerular filtration rate of 7 mL/min/1.73 m², consistent with stage 5 CKD. Liver function tests, including aspartate aminotransferase, alanine aminotransferase, and gamma-glutamyl transferase, were within normal limits.

4) Peripheral Blood Morphology : Peripheral blood examination demonstrated normal differential counts of neutrophils, lymphocytes, monocytes, eosinophils, and basophils, with platelet count and morphology within normal limits.

5) Urine Analysis : Urinalysis revealed elevated levels of occult blood, protein, and leukocytes. Urine microscopic analysis further showed increased red blood cells, white blood cells, and bacterial presence.

8. Systemic Review

1) Sleep : 9 hours from 21:00 pm to 6:00 am, frequent awakening.

2) Appetite : Low appetite, taking three meals daily of half the amount with a special diet (Diabetes-hemodialysis meal, 1600kcal)

3) Urination : Foley catheter keep-state

4) Defecation : Normal stool once every one or two days

5) Fluid Intake : average

6) Face : Pale

7) Tongue : Pale without tongue coating

8) Pulse (脈) : slow and deep (遲, 沈)

9. Treatment

1) Korean herbal Medicine : From the day following admission until May 11, the patient was prescribed Bojungikgi-tang to be administered three times daily, 30 minutes after meals. During the course of hospitalization, an additional herb was incorporated into the formula to further address the patient’s clinical symptoms. The detailed composition of Bojungikgi-tang is provided in Supplementary Table 1 and 2. Table 2 provides variations of Bojungikgi-tang during hospitalization.

2) (Electro)Acupuncture : Beginning on March 6, 2025, acupuncture treatment was administered twice daily. Sterile disposable stainless-steel needles (0.25 mm×40 mm; Dongbang Acupuncture Inc., Korea) were inserted bilaterally at ST36 (足三里), LI4 (合谷), LR3 (太衝), and LU5(尺澤). The needles were retained for 20 minutes per session. Electroacupuncture stimulation was applied at the same acupuncture points using a frequency of 4 Hz, with the intensity adjusted to a level at which the patient perceived electrical stimulation without experiencing discomfort. Electroacupuncture was maintained for 20 minutes per session.

3) Moxibustion : Indirect moxibustion on CV3 (中極), CV6 (氣海) and CV4 (關元)was administered once daily during hospitalization. An electro-moxibustion device routinely used at the Korean Medicine Hospital was applied, providing controlled thermal stimulation combined with mild mechanical compression. Each session lasted 15 minutes. This intervention was intended to support gastrointestinal function, particularly gastric motility, and to alleviate digestive discomfort and poor appetite.

4) Cupping : Cupping therapy was administered daily during hospitalization. A dry cupping technique was selected, as wet cupping was not indicated for this patient. Dry cupping was applied to the Back-shu points (BL13-BL30; 背輸穴), which are specific acupuncture points located on the back along the Bladder meridian, each corresponding to a particular internal organ, on the patient’s back for 5 minutes with the aim of modulating autonomic nervous system balance. This intervention was intended to improve overall systemic regulation and was additionally expected to alleviate insomnia, generalized weakness, and reduced appetite.

5) Western Medicine : During hospitalization, the patient continued her previously prescribed medications; details are provided in Supplementary Table 3. Fosfomycin powder was initiated at admission but was subsequently discontinued at the request of the patient’s family due to concerns regarding diarrhea. On April 4, the patient developed cystitis, and fosfomycin therapy was reinitiated. In addition, given the patient’s asthma-COPD overlap syndrome, accompanied by increased sputum production noted on March 15, Mukaran Cap 200mg was prescribed and continued until discharge.

11. Evaluation Methods

1) Blood tests : During maintenance hemodialysis, blood examinations were conducted weekly to monitor temporal trends and overall changes throughout the hospital course.

12. Treatment Results

As the patient was undergoing hemodialysis, blood tests were conducted at least once per week. The results were used to monitor overall trends and changes throughout the course of the hospitalization and the use of traditional Korean medicinal treatments. At admission, blood urea nitrogen (BUN) was 25 mg/dL and serum creatinine were 4.77 mg/dL, corresponding to an estimated glomerular filtration rate (eGFR) of 7.7 mL/min/1.73 m², consistent with CKD stage 5. Subsequent laboratory testing demonstrated gradual changes in renal indices over time. On March 10, BUN and creatinine were 30 mg/dL and 4.27 mg/dL, respectively (eGFR 8.81 mL/min/1.73 m²). On March 13, values were 23 mg/dL and 3.83 mg/dL (eGFR 10.05 mL/min/1.73 m²), and on March 18 they were 32 mg/dL and 3.58 mg/dL (eGFR 10.91 mL/min/1.73 m²). By March 26, BUN decreased to 15 mg/dL and creatinine to 3.09 mg/dL (eGFR 13.03 mL/min/1.73 m²), with further reductions noted on March 31 (14 mg/dL and 2.49 mg/dL; eGFR 16.92 mL/min/1.73 m²). During April, renal indices continued to show favorable temporal changes. On April 3, BUN and creatinine were 13 mg/dL and 2.28 mg/dL (eGFR 18.82 mL/min/1.73 m²), and on April 10 they were 11 mg/dL and 1.69 mg/dL (eGFR 27.03 mL/min/1.73 m²). Thereafter, values fluctuated within a similar range. At the final measurement on May 15, BUN was 19 mg/dL, creatinine was 1.60 mg/dL, and eGFR was 28.88 mL/min/1.73 m² (Fig. 2). Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were 32 U/L and 12 U/L, respectively, both within reference ranges at admission. Serial monitoring showed no persistent abnormalities in liver enzymes during hospitalization. A transient elevation in AST (49 U/L) was observed on March 18, while ALT remained within the reference range (22 U/L). Subsequent measurements demonstrated normalization of AST and ALT levels, which remained within reference ranges through the end of follow-up (Fig. 3) Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were elevated at 120 mm/hr and 5.35 mg/dL, respectively, at the time of admission. Urinalysis and additional evaluation identified a concurrent urinary tract infection. Serial measurements demonstrated a downward trend in inflammatory markers over time. By April 3, ESR had decreased to 63 mm/hr and CRP to below 0.5 mg/dL. Mild fluctuations were observed thereafter; however, ESR and CRP levels remained lower than admission values throughout the remainder of hospitalization (Fig. 4). At admission, the patient tested positive for vancomycin-resistant enterococci (VRE), and contact isolation precautions were implemented in accordance with institutional infection-control protocols. Healthcare personnel used protective gowns and gloves during patient contact and specimen collection. Follow-up surveillance cultures obtained on April 8, April 15, and April 21 were negative for VRE. After three consecutive negative results, isolation precautions were discontinued. The entire flow of the hospitalization is depicted on Table 4.

In this case, integrative treatment was associated with clinically meaningful improvements across renal, inflammatory, and infectious parameters without evidence of hepatotoxicity. Renal function showed a sustained upward trend, with serum creatinine decreasing from 4.77 to 1.60 mg/dL and eGFR improving from 7.7 to 28.9 mL/min/1.73 m², corresponding to reclassification from CKD stage 5 to stage 4, despite minor fluctuations during follow-up. Liver function remained stable throughout hospitalization, with only a transient and self-limited elevation in AST that resolved without intervention. Inflammatory markers demonstrated a marked decline, with CRP normalizing and ESR significantly reduced from baseline, suggesting attenuation of systemic inflammation. In addition, VRE colonization resolved within one month, as evidenced by three consecutive negative cultures, allowing discontinuation of isolation precautions. Collectively, these findings indicate a pattern of improved renal function, reduced inflammatory burden, stable hepatic safety, and recovery of host defense, suggesting a favorable clinical course during integrative treatment.

CKD and end-stage kidney disease (ESKD) is a growing global public health problem, driven mainly by aging populations and increasing diabetes and hypertension, with rising incidence and prevalence, especially in the United States. Most patients have major comorbidities leading to poor quality of life and high mortality, primarily from cardiovascular causes⁶. Kidney transplantation, peritoneal dialysis, and hemodialysis are the three main treatments for patients with ESKD; although transplantation offers the best survival and quality of life, its use is limited by organ shortages, patient age, severe illness, and access disparities, particularly affecting disadvantaged groups. Hemodialysis, which is suitable for most patients and can serve as a bridge to transplantation, is therefore the most common therapy worldwide and currently sustains the lives of approximately 2 million patients with ESKD⁷. However, a previous study has shown that frailty was highly prevalent, about 50% overall, in patients with stage 5 CKD starting hemodialysis or peritoneal dialysis⁸. However, transfusion therapy may pose additional risks of renal and systemic complications. In this population, maintaining renal safety is a major clinical concern.

Bojungikgi-tang is a classical Korean herbal formula traditionally used to enhance gastrointestinal function and augment systemic Qi. Recent systematic reviews and clinical investigations suggest potential benefits in conditions such as chronic fatigue syndrome, atopic dermatitis⁹, chronic tinnitus¹⁰, chemotherapy-induced leukopenia¹¹, coronavirus-related conditions¹², and cancer-related fatigue, with clinically meaningful improvements reported in selected patient populations. In addition, preclinical in vivo studies indicate that Bojungikgi-tang may improve immune dysfunction associated with Qi-deficiency states, supporting its role as an adjunctive therapeutic option in conditions characterized by fatigue and impaired host defense. Despite its widespread clinical use, evidence regarding the renal and hepatic safety of Bojungikgi-tang in elderly patients with CKD is limited. Therefore, this study aimed to describe changes in renal function and the safety of liver function in an elderly patient with CKD who received a blood transfusion accompanied by Korean medicine treatment, including Bojungikgi-tang.

In this case, Bojungikgi-tang was selected as the primary herbal intervention in consideration of the patient’s frailty, prolonged weakness, and multisystem functional decline. Prior to the deterioration in renal function, the patient exhibited persistent gastrointestinal symptoms and dyspnea, suggesting early impairment of systemic physiological resilience. From a traditional Korean medicine perspective, dysfunction in one organ system can propagate to others, leading to a global decline in homeostasis. Thus, the progression to advanced renal dysfunction was interpreted not only as kidney impairment but also as part of a broader pattern involving gastrointestinal and systemic weakness. In addition, the presence of VRE colonization suggested compromised host immunity. Bojungikgi-tang, traditionally indicated for augmenting Qi and restoring overall vitality, was therefore selected to enhance systemic function, support immune competence, and potentially improve renal and gastrointestinal function in an integrated manner. For this patient,Cimicifuga heracleifolia and Angelica gigas, both traditional components of Bojungikgi-tang, were initially excluded from the formulation. This decision was based on prior reports suggesting potential hepatotoxicity associated with Cimicifuga species¹³ and a possible risk of hyperkalemia with Angelica gigas. During treatment, the patient’s serum potassium levels remained stable; therefore, Angelica gigas was subsequently introduced without adverse effects. In addition, Dolichos lablab was incorporated in April to support gastrointestinal function and enhance mucosal protection.

The constituents of Bojungikgi-tang are usually focused on augmenting strength and homeostasis. In this particular case, Astragalus¹⁴ and Glycyrrhizia¹⁵ is known to ameliorate renal injury by relieving inflammatory responses, and Atractlyodes also relieves renal injury through the inhibition of SIRT1/Nlrp3/Caspase-1 pathway¹⁶. Panax ginseng shows potential benefits in frailty-related conditions such as fatigue, metabolic disorders, cardiovascular health, cognition, and immunity, likely mediated by ginsenosides¹⁷. Poria and Polyporus are effective in protecting renal injury through various pathways, including the NF-κB-NOX4 signaling pathway¹⁸. In this patient, renal function showed clinically meaningful improvement, resulting in reclassification from CKD stage 5 to stage 4. This finding is clinically significant, given the limited therapeutic options currently available to reverse or meaningfully improve renal function in advanced CKD. On March 18, a transient elevation in AST and ALT levels was observed. This increase was not sustained and appeared to represent a short-lived fluctuation rather than a persistent trend, potentially associated with the initiation of Mukaran capsules. Importantly, the patient remained clinically stable, and liver enzyme levels returned to baseline without intervention, indicating no evidence of clinically significant hepatotoxicity. On May 2, a transient increase in blood urea nitrogen and serum creatinine levels was observed. Although no specific etiological factor could be identified, this fluctuation may be attributable to changes in the patient’s clinical environment following release from isolation after three consecutive negative test results. Notably, the elevation was not sustained, suggesting a temporary and context-related variation rather than a progressive decline in renal function. This finding supports the safety of the Korean herbal medicine as an adjunctive therapy in chronically ill patients, although confirmation in larger, controlled studies is warranted.

In the present case, the patient tested positive for vancomycin-resistant enterococci (VRE) at admission but was released from isolation within one month. Although VRE colonization is uncommon in healthy individuals, it is highly prevalent in ICU settings, which function as major reservoirs sustaining VRE within healthcare systems. Previous meta-analytic data indicate a pooled VRE colonization prevalence of approximately 8.8% at ICU admission, with stable rates reported between 1995 and 2010, and a similar pooled acquisition rate during ICU stay¹⁹. Spontaneous clearance of VRE within one month of this case suggests recovery of host immune competence and therefore improvement in the immune system. The temporal association with Bojungikgi-tang administration supports its potential role as an adjunctive therapy aimed at enhancing host immune function and resilience against multidrug-resistant organisms. While causality cannot be established from a single case, this observation underscores the need for controlled studies to evaluate the immunomodulatory effects of Bojungikgi-tang in patients colonized with resistant pathogens.

Therefore, this case provides clinical evidence supporting Bojungikgi-tang in an elderly patient with CKD stage 5, marked positive for vancomycin-resistant enterococci. Future comparative clinical trials and mechanistic studies in CKD are needed to clarify the biological pathways through which these herbal formulations exert their therapeutic effects. In addition, sustained collaborative research integrating Western and Korean medicine approaches will be essential to establish evidence-based treatment protocols and to improve clinical outcomes in elderly patients with chronic diseases.

This case suggests that Bojungikgi-tang, a traditional Korean herbal formulation, may serve as a supportive therapeutic option in elderly patients with advanced CKD undergoing hemodialysis and complicated by vancomycin-resistant enterococci colonization. Following treatment, the patient demonstrated clinically meaningful improvements in blood urea nitrogen and serum creatinine, with reclassification from CKD stage 5 to stage 4, in the absence of additional transfusions or newly introduced medications, and without evidence of hepatic dysfunction. Notably, VRE colonization resolved within four weeks, allowing discontinuation of isolation precautions.

Although limited by the nature of a single case report, these observations align with previously proposed mechanisms of blood- and Qi-supporting formulas and highlight the need for well-designed comparative and mechanistic studies to clarify the role of Korean medicine approaches in integrated CKD care and in improving outcomes and quality of life among elderly patients with chronic disease.