Traditional Chinese medicine in CKD: myths, facts, and evidence

Traditional Chinese medicine (TCM) is increasingly used among patients with chronic kidney disease (CKD), particularly in regions where healthcare resources, accessibility and cultural acceptance influence treatment choices. However, its role in the treatment of CKD remains controversial, with conflicting perceptions ranging from therapeutic promise to concerns regarding unproven efficacy and potential toxicity. In this review, we critically examine some myths and facts surrounding TCM use in CKD through the framework of evidence-based medicine. Randomized evidence remains limited, but a few trials have reported clinically relevant signals. In patients with type 2 diabetes and CKD, the multicenter SCHEMATIC trial found that add-on Rehmannia-6-based Chinese medicine was associated with a slower decline in eGFR over 48 weeks. In membranous nephropathy, an earlier multicenter randomized trial of Shenqi particle reported reductions in proteinuria and remission outcomes comparable with conventional immunosuppressive therapy. These findings are hypothesis-supporting rather than definitive: neither trial established a reduction in kidney failure, cardiovascular events or mortality, and independent confirmation is lacking. Importantly, safety should not be inferred from natural origin or historical use. Product quality, botanical authentication, pharmacokinetics, toxicological evaluation, herb-drug interactions and pharmacovigilance are essential components of responsible clinical evaluation. Future research should move beyond the broad question of whether 'TCM works' and instead focus on product-specific assessment using rigorous trial methodology, standardized manufacturing, precision CKD phenotyping and internationally applicable outcome measures. Chinese herbal medicines should neither be dismissed solely because they are traditional nor accepted solely because they are natural. Their future role in CKD care should be determined by the same principles applied to any therapeutic intervention: reproducible quality, demonstrated clinical benefit and an acceptable benefit-risk profile.