Background : Conventional treatment for cardiorenal syndrome (CRS) is frequently associated with drug resistance and limited clinical success. We aimed to explore a new approach utilizing Boiogito (TJ-20), a traditional Japanese medicine (Kampo), in combination with conventional treatment for patients with CRS.
Methods and Results : We enrolled 26 patients with CRS (18 men ; mean age, 77±8.4 years ; mean serum brain natriuretic peptide (BNP), 241.5±196.6pg/mL ; mean estimated glomerular filtration rate (eGFR), 40.02±10.54mL･min^-1.1.73m^-2). Treatment with TJ-20 was started at an average dose of 4.6±1.5g/day, which was increased to 5.2±1.2g/day at 3.5 months and to 5.9±1.5g/day at 9.4 months. TJ-20 treatment significantly increased mean eGFR (mL･min^-1.1.73m^-2) to 44.60±10.76 at 3.5 months (P＝0.001), and to 45.93±11.57 at 9.4 months (P＝0.0004). In addition, the New York Heart Association functional classification improved (P＝0.019), and serum BNP levels decreased significantly to 195.5±145.7pg/mL at 3.5 months (P＝0.008) and to 163.3±130.2pg/mL at 9.4 months (P＝0.007). The increase in eGFR had no correlation with the decrease in BNP level, indicating independent effects on both renal function and heart failure status.
Conclusions : TJ-20 can benefit both renal function and heart failure status in patients with CRS. Alternative medicine utilizing TJ-20 may provide a novel and useful strategy for the difficult management of patients with CRS.

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We report a 38-year-old man who showed Jacksonian march epilepsy from the left arm at first, the cause of which was hypertrophic cranial pachymeningitis localized to the right parietal area. There were some abnormal laboratory findings including positive PR-3 ANCA and a slightly elevated level of IgG4 in serum. Brain biopsy disclosed thickened meningeal tissues with heavy infiltration of mononuclear cells, but the vast majority of them lacked IgG4 immunoreactivity. There was no granuloma formation. Histopathological findings with chronic inflammation and positive PR-3 ANCA in serum indicated that localized hypertrophic pachymeningitis was caused by granulomatosis with polyangiitis (GPA). Since two cycles of steroid pulse therapy did not result in complete remission of the patient’s neurological disorder, methotrexate was added to oral administration of predonisolone. MRI at 40 days after this treatment revealed disappearance of thickened meninges with local edema of the involved cortex, and the patient then returned to his previous work. The localized form of hypertrophic cranial pachymeningitis might be one manifestation of GPA occurring only at the dura, and the combination of methotrexate and predonisolone was considered to be useful for the treatment of this intractable meningitis.

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