Journal of Traditional Chinese Medical Sciences (2017) 4, 317e321

Available online at www.sciencedirect.com

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journal homepage: http://www.elsevier.com/locate/jtcms

Pattern of disharmony between the heart

and kidney: Theoretical basis, identification
and treatment
Jian Dong, Tianfang Wang*, Lihong Zhao, Xinran Chen

School of Chinese Medicine, Beijing University of Chinese Medicine, China

Received 18 June 2017; accepted 18 September 2017

Available online 2 January 2018

KEYWORDS Abstract “Harmony between the heart and kidney” refers to the physiological relationship
Harmony between between these two zang organs in Chinese medicine, while “disharmony between the heart
the heart and kidney; and kidney” (also called disharmony between fire and water) refers to the pathological state.
Disharmony between The pattern of disharmony between the heart and kidney is widely observed in patients with
the heart and kidney; insomnia, anxiety disorder and menopausal syndrome, etc.. In order to gain a full and systema-
Pattern of tical understanding of this pattern, from the perspective of ancient Chinese philosophy and
disharmony between zang-fu theory in Chinese medicine, we systematically reviewed and discussed the functions
the heart and kidney; and physiological characteristics of the heart and kidney, the origin and development of the-
Coptis and Donkey- ories relating to heartekidney relationship, the pathogenesis and identification of the pattern,
Hide Gelatin as well as the commonly used classical formulas for its treatment, including Coptis and Donkey-
 a
Hide Gelatin Decoction (Huánglián Eji  o Ta
ng) and Grand Communication Pill (Jia otài Wán).
Decoction (Huánglián
 a
Eji  o Ta
ng); Two examples of clinical modifications of these formulas in the treatment of insomnia and
Grand menopausal syndrome are provided in this article. It should be noted that in clinical practice,
Communication Pill these formulas should be used flexibly, and modified in accordance to the condition of the pa-
otài Wán)
(Jia tient.
ª 2017 Beijing University of Chinese Medicine. Production and hosting by Elsevier B.V. This is
an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/4.0/).

In Chinese medicine, the heart and kidney are two closely- while “disharmony between the heart and kidney” (or
related zang organs. “Harmony between the heart and “disharmony between fire and water”) indicates the path-
kidney” (or “harmony between fire and water”) refers to ological state. As the meanings of these terms have been
the physiological relationship between these two organs, gradually enriched over dynasties, there exist some

* Corresponding author.
E-mail address: tianfangwang2000@163.com (T. Wang).
Peer review under responsibility of Beijing University of Chinese Medicine.

https://doi.org/10.1016/j.jtcms.2017.12.001
2095-7548/ª 2017 Beijing University of Chinese Medicine. Production and hosting by Elsevier B.V. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
318
disputes about their connotations. Despite that, “the
pattern of disharmony between the heart and kidney”, a
term referring to the resulting pattern, is specifically used
to represent the disorder with the pathogenesis of heart
fire hyperactivity and kidney yin/yang deficiency. This may
be categorized into three separate groups of manifesta-
tions. Firstly, vexation, insomnia, palpitations and dream-
disturbed sleep are symptoms directly associated with hy-
peractive heart fire. Secondly, dizziness, tinnitus, soreness
and weakness in the lumbar region and knees, low grade
tidal fever, night sweats and frequent seminal emission are
symptoms directly correlated to kidney yin deficiency.
Lastly, cold pain in the lumbar region and knees, or
numbness, tingling and coldness in the lower limbs, or
edema in the lower limbs, and impotence are symptoms
directly related to kidney yang deficiency. Clinically, such a
pattern is widely observed in various diseases, such as
insomnia, anxiety disorder and menopausal syndrome,
etc.1e5 In this article, the theoretical basis, common
manifestations and classical formulas concerning this
pattern are systematically reviewed and discussed, which
will guide the identification and treatment of this pattern.
Theoretical basis
Main functions and physiological characteristics of
the heart and kidney
The heart’s functions could be summarized as follows.
Firstly, the heart governs the blood and vessels. This means
the rhythmic beating of the heart propels blood circulation
all over the body. Secondly, the heart governs the shen. The
shen here corresponds to the mental activities governed by
the brain in modern psychology, including cognitive activ-
ities, emotions and mood, will, and consciousness, etc.
According to the yin-yang theory in Chinese medicine,
the heart is located in the upper jiao, and pertains to yang.
According to the five elements theory, the heart pertains to
fire. The yang qi of the heart provides the basis for all its
functional activities. The heart yang qi, with its warming
and propelling functions, promotes blood circulation and
invigorates the heart shen, thus playing a dominant role in
maintaining the overall functions of the body.
The kidney’s main functions may be summarized as fol-
lows. Firstly, the kidney stores essence. The essence stored
in the kidney promotes growth, development and the
reproductive functions of the body, and it is also closely
related to the generation of blood. Secondly, the kidney
governs water. This means the kidney regulates water
metabolism through the qi transformation function of the
kidney yang; Lastly, the kidney governs qi reception, in the
form of assisting the lung in regulating respiration.
According to the yin-yang theory, the kidney is situated
in the lower jiao, and pertains to yin. According to the five
elements theory, the kidney pertains to water. As the
foundation of innate constitution, the kidney houses innate
yin and yang, so it is regarded as the fundamental root of
yin fluid and yang qi for all zang-fu organs within the human
body. As the kidney is characterized by “housing and stor-
ing”, pathological changes of the kidney often belong to the
deficiency type.
J. Dong et al.
Origin and development of the theory of “harmony
between the heart and kidney”
The term “harmony between the heart and kidney” was
firstly put forward in Shenzhai Zhou’s Comprehensive Book
on Chinese Medicine (Shènzha i Yı´shu
 ) in the Ming Dynasty.
The development of its fundamental theories, however,
dates back to more ancient times. In I Ching (Yı` Jıng), one
of the oldest classics on Chinese philosophy, 64 hexagrams
are recorded, in which each is composed of two combined
trigrams from the eight trigrams (ba gua) in total. The eight
trigrams and the natural phenomena they represent are
illustrated in Fig. 1. The broken and unbroken lines in the
trigrams represent yin and yang respectively. Each of the 64
hexagrams embodies a state, among which the Kan-Li Co-
ordination Hexagram ( ) reflects the harmonious and
balanced state between water and fire through dynamic
interaction. This image is composed of two trigrams called
Kan (☵) and Li (☲), which on the whole represent water
and fire respectively. Therefore, the interaction between
Kan and Li reflects the coordination between yin and yang.
Although Kan (☵) represents yin on the whole, there is yang
within it, resulting in an ascending tendency; similarly,
there is a descending tendency for Li (☲), the represen-
tation of yang. In a word, the Kan-Li Coordination Hexa-
gram reflects the harmonious and balanced state achieved
through the water-ascending and fire-descending move-
ment. Such an interpretation of the Kan-Li Coordination
Hexagram has laid the foundation for the development of
the theory of harmony between the heart and kidney in
Chinese Medicine.6
The physiological relationship between the heart and
kidney was firstly discussed in The Yellow Emperor’s Inner
Classic (Huángdı` Nèijıng). In later dynasties, the under-
standing of the heartekidney relationship has been gradually
enriched and deepened. In Important Formulas Worth a
Thousand Gold Pieces for Emergency (Bèijı´Qia njın Yào fa
ng)
in the Tang Dynasty, Simiao Sun borrowed the concept of
harmony between Kan (water) and Li (fire) from I Ching and
analogized it to the heartekidney relationship in Chinese
Figure 1 Eight trigrams and their corresponding natural
phenomena in bagua arrangement.
Pattern of disharmony between the heart and kidney
medicine. He put forward the term “harmony between fire
and water” in representation of the heartekidney relation-
ship for the first time in a Chinese Medicine book. In the Yuan
Dynasty, Danxi Zhu furtherly explained the heartekidney
relationship with above-mentioned water-ascending and fire-
descending theory. In the Ming Dynasty, Shenzhai Zhou
explicitly explained the mechanism of heart-kidney commu-
nication in Shenzhai Zhou’s Comprehensive Book on Chinese
Medicine. In conclusion, it could be inferred that the inter-
pretation of heartekidney relationship in Chinese Medicine
is greatly influenced by the Kan-Li Coordination theory
in I Ching.
To sum up, harmony between the heart and kidney
emphasizes the harmonious coordination between the
heart and kidney achieved through the dynamic descending
and ascending movement of yin and yang in the heart and
kidney. As the heart is located in the upper part of the
body, the heart yang qi should descend to strengthen the
kidney yang qi’s function of warming the kidney yin fluid, so
as to prevent excessive coldness in the kidney. The kidney
is situated in the lower part of the body, hence the kidney
yin fluid should ascend to help the heart yin fluid to control
the heart yang qi, preventing hyperactive heart yang qi
from transforming into fire. In summary, the heart-kidney
harmonious communication is based on the dynamic bal-
ance between the ascending of kidney yin and descending
of heart yang.3
How this pattern is formed
If the heart-kidney balance is disturbed, there would be
inadequate/no communication between the heart yang qi
and kidney yin fluid. Such a pathological condition is called
“disharmony between the heart and kidney”, or “dishar-
mony between fire and water”.7
Generally, there are two different pathogeneses: (1)
heart fire hyperactivity & kidney yin deficiency. The
initial cause of this condition is excessive consumption of
kidney yin as a result of chronic disease or sexual indul-
gence. Without adequate kidney yin fluid going upward to
help the heart yin fluid constrain the heart yang qi, there
would be hyperactive heart fire, thus resulting in dishar-
mony between the heart and kidney with deficient kidney
yin in the lower part of the body and hyperactive heart fire
in the upper part of the body. (2) heart fire hyperactivity &
kidney yang deficiency. Initially, there is hyperactive heart
fire due to external contraction of heat-fire pathogenic
factors or stagnant qi transforming into fire as a result of
emotional strain. The heart fire blazes upward without
control, resulting in heart yang qi failing to go downward to
help the kidney yang qi warm kidney yin fluid, leading to
disharmony between the heart and kidney with hyperactive
heart fire in the upper part of the body and deficient kidney
yang in the lower part of the body.4
Identification
According to the different pathogeneses and clinical man-
ifestations, the pattern of disharmony between the heart
and kidney could be summarized as the following two sub-
patterns.
319
Kidney yin deficiency & heart fire hyperactivity
This is the combination of two separate patterns: (1) heart
fire hyperactivity. This is chiefly manifested as vexation,
insomnia, palpitations, dream-disturbed sleep, and tongue
ulcers, etc. (2) kidney yin deficiency. This usually presents
as dizziness, tinnitus, forgetfulness, soreness and weakness
in the lumbar region and knees, frequent seminal emission,
dry mouth and throat, feverish sensation in the palms, soles
and chest, low grade tidal fever, night sweats, con-
stipation, deep yellow urine, a red tongue with scanty or no
coating, and a thready rapid pulse, etc..
As the kidney yin fluid is deficient in the first place,
there is not enough kidney yin fluid being evaporated up-
ward to restrict heart yang qi. Without restriction, the
hyperactive heart yang qi would be transformed into heart
fire. As the heart fire harasses the heart shen (mental ac-
tivity), this leads to vexation, insomnia, palpitations, and
dream-disturbed sleep. As the heart fire goes along the
heart channel to the tongue, there would be tongue ulcers.
When deficient kidney yin fluid fails to nourish the brain and
ears, there is dizziness, tinnitus and forgetfulness. When
deficient kidney yin fluid fails to nourish the lumbar region
and knees, there is a manifestation of soreness and weak-
ness in the lumbar region and knees. Without sufficient
kidney yin fluid, deficient fire is generated to disturb the
essence chamber (where the sperms are stored) and
weaken its storing function, thus frequent seminal emission
is seen. Deficient heat is generated internally as a result of
deficient yin and hyperactive yang, leading to dryness in
the mouth and throat, feverish sensation in the palms, soles
and chest, low grade tidal fever and night sweats, etc.
Constipation, deep yellow urine, a red tongue with scanty
or no coating, and a thready rapid pulse are all manifes-
tations of hyperactive heart fire due to yin deficiency.
Heart fire hyperactivity & kidney yang deficiency
This is the combination of two separate patterns: (1) heart
fire hyperactivity. This is chiefly manifested as vexation,
insomnia palpitations, dream-disturbed sleep, tongue ul-
cers, and dryness in the mouth, etc. (2) kidney yang
deficiency. This is chiefly manifested as cold pain in the in
the lumbar region and knees, or numbness, tingling and
coldness in the lower limbs, or edema in the lower limbs,
and impotence, etc.
As the hyperactive heart fire harasses the heart shen,
this leads to vexation, insomnia, palpitations, and dream-
disturbed sleep. Since the heart fire goes along the heart
channel to the mouth and tongue, there would be tongue
ulcers and dryness in the mouth. With hyperactive fire
flaming upward, the heart yang qi cannot descend to help
the kidney yang qi warm the lumbar region, knees and
lower limbs, leading to cold pain in the lumbar region and
knees, or numbness, tingling and coldness in the lower
limbs. As there is abnormal water metabolism due to kidney
yang deficiency, water and fluids tend to retain in the lower
part of the body, resulting in edema in the lower limbs.
Kidney yang deficiency may also cause decreased sexual
function, so impotence could be seen.
Clinically, apart from the two sub-patterns mentioned
above, more complicated sub-patterns could also be
320
observed, such as kidney yin-yang deficiency and heart fire
hyperactivity. Therefore, for each case, all information
gained from the four diagnostic methods should be taken
into consideration to make a careful differentiation.
Treatment
Based on the causes and pathogenesis of this pattern
mentioned above, the guiding treatment principle should
be clearing hyperactive heart fire and supplementing kid-
ney yin/yang so as to restore harmonious coordination be-
tween the heart and kidney.8 Specifically, for the sub-
pattern with hyperactive heart fire and deficient kidney
yin, the treatment principle should be nourishing kidney yin
and clearing heart fire; for the sub-pattern with hyperac-
tive heart fire and deficient kidney yang, the treatment
principle should be clearing heart fire and directing heart
yang downward to warm the kidney yang or directly sup-
plementing kidney yang. Clinically, when treating these
two sub-patterns with Chinese medicines, Coptis and
 ao Tang) and
Donkey-Hide Gelatin Decoction (Huánglián Eji
otài Wán) are often cho-
Grand Communication Pill (Jia
sen and used with modifications according to the actual
conditions.
Classical formulas
Coptis and Donkey-Hide Gelatin Decoction
This formula was firstly recorded in Treatise on Cold
Damage (Sha nghán Lùn) by Zhongjing Zhang in the East Han
Dynasty. It was initially designed for the treatment of shao
yin pattern chiefly manifested as vexation and insomnia.9
Now it is often used in the treatment of disharmony be-
tween the heart and kidney with heart fire hyperactivity
and kidney yin deficiency. The composing medicines and
their dosages are: coptis rhizome (Coptis chinensis FRANCH)
12 g, scutellaria (Scutellaria Baicalensis GEORGI) 6 g, white
pony root (Paeonia lactiflora PALL) 6 g, donkey-hide gelatin
(Equus asinus LINNAEUS) 9 g and two egg yolks.
This formula works to relieve vexation and calm the
heart shen by nourishing kidney yin and clearing heart fire.
In this formula, coptis rhizome, being bitter and cold, en-
ters into the heart channel to clear heart fire. Donkey-hide
gelatin, being sweet and neutral, nourishes the kidney yin
to relieve dryness. They two are the chief medicines and
used in combination to relieve vexation and tranquilize the
heart shen by nourishing the kidney yin and clearing heart
fire. Scutellaria, bitter and cold, assists coptis rhizome to
clear heart fire. White pony root, sour and cold, assists
donkey-hide gelatin to nourish blood and constrain yin. The
egg yolk enters into both the kidney and heart channels to
supplement the strength in nourishing kidney yin and
clearing heart fire.
Grand Communication Pill
This formula was derived from Han’s Clear View of Med-
icine (Hánshı` Yito ng) by Mao Han in the Ming Dynasty.
Clinically, it is often used in the treatment of disharmony
between the heart and kidney with heart fire hyperac-
tivity and kidney yang deficiency. The composing medi-
cines and their dosages are: coptis rhizome (Coptis
J. Dong et al.
chinensis FRANCH) 15 g and cinnamon bark (Cinnamomum
cassia PRESL) 1.5 g.
This formula works to restore coordination between the
heart and kidney by clearing heart fire and directing heart
yang qi downward to supplement kidney yang qi. In this
formula, coptis rhizome is used as the chief medicine.
Being bitter and cold, it enters into the heart channel to
clear heart fire and relieve vexation and insomnia. In
contrast, cinnamon bark, sweet and pungent, enters into
the kidney channel to direct heart yang qi downward, thus
helping kidney yang qi to warm kidney yin fluid. As the
amount of the latter is designed to be only 1/10 of that of
the former, the small amount of cinnamon bark is used with
the appropriate strength to prevent coptis rhizome from
damaging the kidney yang, without the concern of gener-
ating extra heart heat/fire.
Two examples of clinical modifications
According to the findings from data mining and literature
researches, the pattern of disharmony between the heart
and kidney is widely seen in insomnia, anxiety disorder, and
menopausal syndrome etc.10 Regardless of disease differ-
ence, as long as it is diagnosed as the pattern of disharmony
between the heart and kidney, the treatment principle
should be the same: restoring the heart-kidney balance by
clearing heart fire and supplementing kidney yin/yang.
Clinically, both the patient’s constitutional tendency and
the development stage of the disease should be taken into
consideration. Combined with the identification of disease
and pattern, more accurate diagnosis could be made, and
treatment could be practiced in the form of combinations
or modifications of the above-mentioned formulas. The
following are two examples on how to modify these for-
mulas in different clinical conditions.
Insomnia due to kidney yin deficiency and heart fire
hyperactivity
This form of insomnia is caused by heart fire hyperactivity
which manifests as difficulty in falling asleep or even
staying up all night, vexation and irritability, and kidney yin
deficiency which presents as dizziness, tinnitus, soreness
and weakness in the lumbar region and knees, constipation,
deep yellow urine, dry mouth, thirst, a red tongue with
scanty coating, and a thready rapid pulse. The treatment
principle is to tranquilize the heart shen and relieve vexa-
tion by clearing heart fire and nourishing kidney yin, thus
restoring the heart-kidney communication.
Coptis and Donkey-Hide Gelatin Decoction should be
chosen and used with modifications. The composition of the
formula and suggest dosage is: coptis rhizome 10 g, scu-
tellaria 10 g, white pony root 15 g, donkey-hide gelatin
10 g, and two egg yolks. For patients suffering from severe
insomnia, fleeceflower caulis (Polygonum multiflorum
THUNB) 15 g and spiny zizyphus seeds (Ziziphus jujube MILL.
Var. spinose (BGE)) 15e30 g can be added to strengthen the
effect of calming the mind to help sleep. If there are
obvious manifestations of yin deficiency, anemarrhena
thizome (Anemarrhena aspheloides BGE) 10 g and rehman-
nia root (Rehmannia glutinosa LIBOSCH) 15 g can be used to
strengthen the effect of nourishing yin, relieve dryness and
clearing heat.11e13
Pattern of disharmony between the heart and kidney
Menopausal syndrome due to kidney yin-yang deficiency
and heart fire hyperactivity
Patients usually present with abnormal menstruation or
amenorrhea, hot flashes and sweating, insomnia, dream-
disturbed sleep, palpitations, irritability, vexation or even
restlessness, cold pain in the lumbar region and knees, or
numbness, tingling and coldness in the lower limbs, or
edema in the lower limbs, a red or pale red tongue, and a
deep thready or deep thready rapid pulse. This condition
should be treated following the therapeutic principle of
clearing heart fire to calm the heart shen and supple-
menting kidney yin-yang so as to restore heart-kidney
communication.14e16
Coptis and Donkey-Hide Gelatin Decoction and Grand
Communication Pill should be used in combination with
modifications. The composition and dosage of the com-
bined formula is: coptis rhizome 10 g, scutellaria 10 g,
white pony root 15 g, donkey-hide gelatin 10 g, cinnamon
bark 3 g and two egg yolks. If there are intense hot flashes
and sweating, cornus (Cornus officinalis SIEB. & ZUCC) 15 g
and oyster shell (Ostrea Gigas THUNBERG) 30 g can be added
to secure the exterior to stop excessive sweating. For pa-
tients with obvious cold signs, Morinda root (Morinda offi-
cinalis How) 15 g and Chinese dodder seeds (Cuscuta
chinensis LAM) 15 g can be added in order to enhance the
effects of warming the kidney yang. For patients with se-
vere insomnia, spiny zizyphus seeds 15e30 g can be added
to calm the mind.
To sum up, the theory of “harmony between the heart
and kidney” in Chinese medicine stresses the physiologi-
cally heart-kidney balance maintained through the dynamic
descending and ascending movements of yin fluid and yang
qi. Any disturbance to such coordination could lead to
disharmony between the heart and kidney. The pattern of
disharmony between the heart and kidney often refers to
the disorder with the pathogenesis of heart fire hyperac-
tivity and kidney yin and/or yang deficiency. Such a pattern
is frequently observed in patients with insomnia, anxiety
disorder and menopausal syndrome, and treated under the
guiding principle of clearing heart fire and supplementing
kidney yin and/or yang to restore heart-kidney coordina-
tion. Clinically, these two formulas mentioned in this
article should be used flexibly, and modified in accordance
to the actual condition of the patient.
Funding
This work was supported by the Government Sponsored
Funds for Research Development of Beijing University of
321
Chinese Medicine: Standardization of TCM Symptoms and
Patterns (Grant no.: 2016-ZXFZJJ-021).
References
1. Committee for Terms in TCM. Chinese Terms in Traditional
Chinese Medicine and Pharmacy, 2005. Beijing, China: Science
Press; 2004:99e100 [Chinese].
2. Wang TF. Diagnostics of Traditional Chinese Medicine (Fang
TY, trans). 2nd ed. Beijing, China: People’s Medical Publishing
House; 2007:369e370.
3. Li DX, Liu YC. Fundamentals of Traditional Chinese Medicine.
2nd ed. Beijing, China: People’s Medical Publishing House;
2011:291e292 [Chinese].
4. Li CD. Diagnostics in Traditional Chinese Medicine. Beijing,
China: China Press of Traditional Chinese Medicine; 2016:
176e177 [Chinese].
5. Li XY, Yang BC. Discussion on the interaction of heart and
kidney. Shanghai J Tradit Chin Med. 2014;48:31e34 [Chinese].
6. Li WN. The Origin of Heart and Kidney Correlation in TCM and
Discussions on Clinical Practice. Guangzhou University of Chi-
nese Medicine; 2011:3e4 [Chinese].
7. Qu SH, Liu YX. Summary analysis of heart kidney disharmony
theory and clinical treatment. J Basic Chin Med. 2015;21:
1222e1223 [Chinese].
8. Xu DP, Qi F, Zhao YH. Exploration of the medicine combination
laws in ancient formulas in the treatment of disharmony be-
tween the heart and kidney. Shan Xi Zhong Yi. 2014;35:
236e237 [Chinese].
9. Peng HR. Dictionary of Traditional Chinese Medical Formulas.
9th volume. Beijing, China: People’s Medical Publishing House;
1996:297e298 [Chinese].
10. Yang Z, Sun XF, Yu WM. Study on medication rules of Jiaotong
Xinshen treating principle based on data mining. Chin J Inf
TCM. 2016;23:40e43 [Chinese].
11. Dong HL, Liu HY. Treatment of 36 cases of insomnia (pattern of
heart fire hyperactivity and kidney yin deficiency) with Coptis
and Donkey-Hide Gelatin Decoction. Liaoning J Trad Chin Med.
2009;36:1336 [Chinese].
12. He FH. Treatment of 80 cases of insomnia (pattern of heart fire
hyperactivity and kidney yin deficiency) with Coptis and
Donkey-Hide Gelatin Decoction. Yunnan J Trad Chin Med
Materia Medica. 2010;31:27 [Chinese].
13. Li F. Chinese Medical Formulas. 2nd Volume. Beijing, China:
People’s Medical Publishing House; 2007:1097e1098 [Chinese].
14. Xie M, Zhou R. Chinese Medical Formulas. 2nd ed. Beijing,
China: People’s Medical Publishing House; 2013:230e231
[Chinese].
15. Zhao GP. Chinese Medical Formulas. Beijing, China: Science
Express; 2014:139e140 [Chinese].
16. Yao HJ. Clinical effects of Grand Communication Pill in the
treatment of menopausal insomnia (pattern of disharmony
between the heart and kidney). J Practical Trad Chin Med.
2016;32:657e658 [Chinese].