Kashinath GM*, Hemant B, Praerna C, Nagarathna R and Nagendra HR
Division of Yoga and life sciences, Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA University), Banglore, India
Received Date: March 31, 2014; Accepted Date: May 10, 2014; Published Date: May 16, 2014
Citation: Kashinath GM, Hemant B, Praerna C, Nagarathna R, Nagendra HR (2014) Role of Yoga in Chronic Kidney Disease: A Hypothetical Review. J Nephrol Ther 4:167. doi:10.4172/2161-0959.1000167
Copyright: © 2014 Kashinath GM, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Chronic kidney disease (CKD) is a medical condition characterized by progressive renal dysfunction which leads to permanent renal impairment and premature mortality, which affects patient’s quality of life significantly. Diabetes, hypertension and glomerulo-nephritis are known to be the most common causes of CKD. Recent studies have reported that there is a strong association of oxidative stress, chronic inflammation and psychological stress with CKD. These factors significantly affect the treatment outcome in CKD. Treatment modalities which control these factors can contribute significantly towards CKD management. Yoga is an ancient traditional science which encompasses yogic physical postures (asanas), yogic breathing practices (pranayama), meditations and relaxation techniques. Several scientific studies have shown that yoga reduces blood pressure, heart rate, respiratory rate, oxidative stress, psychological stress and inflammatory conditions. It also improves heart rate variability by bringing balance in autonomic nervous system by reducing sympathetic tone and increasing parasympathetic activity. In several studies, it has been reported that yoga has significant role in the management of non-communicable diseases like diabetes, hypertension, coronary heart diseases etc. Regular yoga practice can help control sugar levels in diabetics, blood pressure in hypertensives and reduce the risk of cardiac complications in patients with heart diseases. Thus, yoga has promising role in the primary and secondary management of CKD as an adjuvant. Here, we compile all these researches and based on this present a yoga module useful in CKD along with necessary precautions to be taken while doing yoga.
Chronic Kidney Disease; Yoga module; Oxidative stress; Sympathetic tone; inflammatory markers
Chronic kidney disease (CKD) is a global health problem, with adverse outcomes of kidney failure, cardiovascular disease (CVD), and premature death. CKD is defined as kidney damage or glomerular filtration rate (GFR) <60 mL/min/1.73 m2 for 3 months or more, irrespective of cause . It is a common and serious problem that adversely affects patient’s health, quality of life, limits life span and increases economical burden to health-care systems worldwide . In a survey by American Medical Society of Nephrology, it was estimated that more than 10% of adults in the United States, which amounts to more than 20 million people, may have CKD. Chances of occurrence of CKD increase after 50 years of age and are most common among adults older than 70 years . Diabetes, hypertension and glomerulo-nephritis are known to be the most common causes of CKD and among these diabetes and hypertension are the leading causes of end stage renal disease (ESRD) . In 2011, diabetes or hypertension was listed as the primary cause for 7 of 10 new cases of ESRD in the United States . Several studies have demonstrated that there is an association of metabolic syndrome (high blood pressure, high serum triglyceride level, elevated fasting glucose level and central obesity) with CKD . CKD further leads to co-morbidities such as hypertension, congestive heart failure, dyslipidemia, and anemia of chronic renal failure .
In this review, some important risk factors for CKD such as sympathetic tone , oxidative stress , chronic inflammation  and psychological stress  have been highlighted and possible role of yoga in management of CKD through modifications of these risk factors have been postulated.
Oxidative stress is potential risk for mortality and morbidity in patient with CKD. Several studies have demonstrated the association of oxidative stress with CKD Particularly in ESRD (End Stage renal Disease) which is mainly because of reduce antioxidant system and increased pro-oxidant activity . Oxidative stress increases as CKD progress , it worsens the CKD and in long run oxidative stress leads to cardiovascular related complications in CKD . Apart from traditional risk factors, chronic inflammation, oxidative stress, malnutrition and endothelial dysfunction are important in CVD development in renal patients .
CKD is characterized by low grade inflammation . Recent scientific studies have demonstrated that CKD patients have elevated level of inflammatory markers. These inflammatory markers are C-reactive protein, IL-6, IL-10 etc., which worsen CKD and hamper the treatment outcome . Inflammation in CKD also increases chances of atherosclerosis .
Researches show that higher sympathetic tone is potentially involved in progression of CKD and higher rate of cardiovascular events in CKD patients . It also promotes the development of target organ damage . There is growing evidence that an important cause of the defect in renal excretory function in hypertension is an increase in renal sympathetic nerve activity .
Sedentary lifestyle and psychological stress are considered as important contributors to non-communicable diseases. Frequent hospitalization, economic conditions, worry about treatment outcome, physical disability, poor family support are common sources of psychological stress in CKD patients. Depression is considered as one of the most common psychological condition in end-stage renal disease (ESRD) which leads to anemia and malnutrition by reducing the oral intake in chronic dialysis patients . In a study, 24% patients on dialysis were having depression and these patients had significantly lower hemoglobin, hematocrit and serum albumin levels and higher C-reactive protein and ferritin levels . Another cross-sectional study reported that patient with ESRD with depression had 2.95 fold more mortality than those without depression . Number of studies show that psychological stress increases oxidative stress  and blood pressure, which further worsens CKD condition and treatment outcome. Hence, stress management should be considered in the management of CKD.
Health-related quality of life (QOL) is an important measure of how disease affects patients' lives. New inventions in modern medical science has increased the life expectancy of patients having chronic disorders such as diabetes, cardiac disease, hypertension and cancer, but at the same time, unfortunately, it failed to improve the quality of life in these patients. This fact is especially true for patients with CKD who are on dialysis . Anemia, pain, depression, anxiety and other comorbidies of CKD further hamper the quality of life of patients .
Yoga is an ancient traditional science which encompasses yogic physical postures (asanas), yogic breathing practices (pranayama), meditations and relaxation techniques. In present era Yoga is accepted as science rather than religion or philosophy. Yoga advocates individual existence in five dimensions and not merely physical. These five dimensions are annamaya kosha (physical body), pranamaya kosha (vital body), manomayakosha (Psychic body), vijanamayakosha (intellectual body) and anandamayakosha (causal body). According to Yoga philosophy, non-communicable diseases are the result of imbalance that starts at manomayakosha level and percolates down to the annamaya kosha level via pranamaya kosha, over a period of time. Therefore, yoga therapy focuses on bringing balance at all these levels of existence through various techniques. Its components such as asanas work at physical level, pranayama works at vital energy level and meditation works at psychological and intellectual levels. Recent evidences show that yoga reduces heart rate, blood pressure and basal metabolic rate by reducing sympathetic activity . It has beneficial effect in many non-communicable diseases such as hypertension, diabetes and cancer. Yoga brings balance in autonomic nervous system by reducing the sympathetic tone and increasing parasympathetic tone . Yoga has also been proven to produce various psychological benefits by reducing stress, anxiety and depression and improving the quality of life . Hence yoga is a comprehensive approach to the complex problem of non-communicable diseases like CKD.
Growing evidences suggest that yoga reduces pulse rate, systolic and diastolic blood pressure, basal metabolic rate by reducing sympathetic tone and improving the parasympathetic tone in non-communicable diseases. It reduces systolic, diastolic and mean blood pressure in the patients with hypertension . Yoga reduces fasting, post-prandial, HbA1c sugar levels, cholesterol in diabetics . Thus, yoga may help in prevention of CKD in patients of diabetes and hypertension which are known to be the main causes of CKD.
Many scientific studies have shown that yoga significantly reduces psychological stress in several physical and psychological ailments . In a study, practice of Hath yoga showed significant reduction in perceived stress and negative effect . In another RCT, there was significant improvement in stress, anxiety and health status compared to relaxation following yoga . Yogic practices inhibit the areas responsible for fear, aggressiveness and rage, and stimulate the rewarding pleasure centers in the median forebrain and other areas leading to a state of bliss and pleasure. This inhibition results in lower anxiety, heart rate, respiratory rate, blood pressure, and cardiac output in students practicing yoga and meditation. Thus it improves the subjective wellbeing and quality of life . Thus, yoga has significant role to play in management of stress related to CKD.
In a study, Hath yoga practice lead to significant improvement in anti-oxidant status and reduced oxidative stress levels in the patients with diabetes . In another study, with 3 months follow up of yoga, there was reduced oxidative stress, BMI and glucose levels in the patients with diabetes type 2 . A systematic review concluded that yoga may reduce many risk factors for CVD including oxidative stress, may improve clinical outcomes, and aid in the management of CVD and other insulin resistance syndrome (IRS) related conditions .
In a study on patients with CKD (ESRD) who were on dialysis, it was found that 30 minutes of hath yoga practice daily for 4 moths showed significant reduction in oxidative stress (malondialdehyde, protein oxidation, phospholipase A2 activity) and increase in anti-oxidant activity (superoxide dismutase and catalase activities). This study demonstrated therapeutic, preventative as well as protective effects of Yoga in ESRD through reduction of oxidative stress . Another study in end stage renal disease patients reported that yoga reduces cholesterol levels . In another randomized controlled study on hemodialysis patients, 12 week yoga intervention yoga has proven to be safe and significantly effective in managing the pain, fatigue, sleep disturbance along with significant improvement in hand grip, significant reduction in creatinine, blood urea, alkaline phosphatase and cholesterol along with significant improvement in erythrocyte and hematocrit count . Yoga therapy has been shown to increase haemoglobin levels in anemic patients , it may also help in improving the Hb% in CKD patients. In another recent study, 10 days Mindfulness-based stress reduction program reported beneficial effect in improving quality and duration of sleep. It was concluded that it has the potential of being an effective, accessible and low-cost intervention that could significantly change transplant recipients' overall health and well-being . Mindfulness meditation also reduced arterial blood pressure by reducing the sympathetic over activity in the chronic kidney disease . Meditation also improved the quality of life and sympathetic over activity in Lupus Nephritis Patients with Chronic Kidney Disease .
(1) Physical postures done with awareness (asanas; 1 minute each, total ~ 10-minute session) to be performed as follows:
A. Standing asanas—Mountain posture with arms stretched and with bound hands (Urdhva-Hastasana), Backward bending, from waist (Ardha chakrasana), and Half-waist-rotation pose (Ardha Kati Chakrasana).
B. Sitting asanas—Extension of the front body (Purvottanasana), Hare pose (Shashankasana), Seated twist (Bharadvajasana/Vakrasana), Butterfly (Tittaliasana)
C. Supine asanas-Reclining bound angle posture (Supta Baddhakonasana), Reclining cross legged posture (Supta Svastikasana), Bridge pose (Setubandhasana), Shoulder stand on a chair (Salamba Sarvangasana), Inverted lake pose (ViparitaKarani), Air releasing pose (pavanmuktasana), Corpse posture (Savasana) with bolster support under chest.
(2) Breathing techniques7 Pranayama, total ~ 10-minute session)-Hands in and out breathing (10 rounds in 2 minutes),hand stretch breathing (10 rounds in 2 minutes),tiger breathing (10 rounds in 2 minutes), alternate nostril breathing (Nadisuddhi; in 5 minutes),left nostril breathing (Chandra AnulomaViloma; 27 rounds in 5 minutes, 4 times per day), humming bee breath (Bhramari; in 2 minutes), Cooling pranayama (Sitali; 9 rounds) and abdominal breathing in lying-down position in 2 minutes.
(3) Yogic relaxation techniques with imagery or mindfulness based stress reduction for 20 minutes at the end of asanas and pranayamas.
(4) Meditations—Mindfulness meditation, Om Meditation, cyclic meditation and Yogic Counselling for 20 minutes.
Few components of yoga such as complete inverted poses like head stand pose (sirsasana), fast breathing practices of kapalabhati and bhastrika should be avoided as they are known to increase the sympathetic activity and raise blood pressure. Apart from it, yogic cleansing procedure of laghushankhapraskhalana and vaman dhauti should be avoided as it may precipitate electrolyte imbalances and increase the load on kidneys. Practice of yoga in conditions like CKD is advisable under medical supervision only.
Yoga being non-invasive, cost-effective therapeutic intervention works at physical and psychological levels. It is effective intervention to reduce the blood pressure, heart rate and inflammatory markers both in healthy individuals and in patients with chronic diseases. Hypertension and diabetes are well known risk factors for CKD. Yoga helps in maintaining the blood sugars, blood pressure and lipid levels in these conditions. Yoga has also been proven to reduce oxidative stress, sympathetic tone, psychological stress and inflammatory markers in chronic diseases. These risk factors hamper treatment outcome of CKD. Yoga reduces general symptoms like fatigue, pain associated with CKD it also improves the hematocrit levels. Hence yoga has potential role as an adjunct in prevention and management of CKD. Further RCTs are needed to explore the role of yoga in CKD. Yoga should be administered with caution under the guidance of an expert as there are some practices which may worsen the condition.