Yoga Therapies for Kidney Disease

 

Yoga Therapies for Kidney Disease

1. Advances in exercise therapy in predialysis chronic kidney disease, hemodialysis, peritoneal dialysis, and kidney transplantation-

Purpose- Chronic kidney disease (CKD) is characterized by poor levels of physical activity which contribute to increased morbidity across the disease trajectory. The short nature, small samples, and poor methodology across most studies have failed to translate the role of exercise in CKD into its adoption as a frontline adjunct therapeutic option. This review focuses on recent advances surrounding the benefits of exercise interventions across the CKD spectrum.

Methods- Chronic kidney disease (CKD) is characterized by poor levels of physical activity which contribute to increased morbidity across the disease trajectory. The short nature, small samples, and poor methodology across most studies have failed to translate the role of exercise in CKD into its adoption as a frontline adjunct therapeutic option. This review focuses on recent advances surrounding the benefits of exercise interventions across the CKD spectrum. Key recent advances in exercise studies have focused on the efficacy of novel intervention strategies across the CKD spectrum. These include high-intensity interval training, virtual reality gaming, intradialytic yoga, electrical stimulation of muscles, blood flow restriction training, and protocols combining exercise with nutritional supplementation. Research is also beginning to explore the role of prehabilitation for patients prior to dialysis and kidney transplantation.

Results- There is an ever-increasing number of clinical studies showing the beneficial role of exercise across the CKD spectrum. Some notable results were an increased exercise capacity, increased protein synthesis, increased microvascular function, increased diameter of cephalic vein, increased diameter of radial artery, increased handgrip strength, improved gait speed, number of stunned cardiac segments was down, increased HRQOL, improved level of activity, high level of satisfaction with intervention, increased power and increased muscular strength.

2. Yoga can serve as relaxation, intra-dialysis exercise for patients on maintenance dialysis-

Purpose- The aim of this study was to evaluate the feasibility of conducting a randomized clinical pilot study to measure the effects of an intradialytic yoga program (IDY) on the quality of life, self-efficacy and physical performance among maintenance hemodialysis patients.

Methods- In the trial, researchers randomized 69 patients on maintenance hemodialysis (the median age was 58 years; half of the patients were women; 88% were African American) to either the IDY group or the education group for 12 weeks. In the IDY group, patients completed multicomponent yoga that included movement, breathing and medication modified for intra-dialysis practice. the IDY group showed a nonsignificant improvement in mental health function at Week 12 (from 51.6 to 53.5) compared with the education group (from 53.5 to 50.2).Patients answered questionnaires at 6 weeks and 12 weeks. Additionally, patients completed the 6-minute walking test at 12 weeks. Researchers considered results of the Kidney Disease Quality of Life (KDQoL) physical function and KDQoL mental function tests primary outcomes. 

Results- Intra-dialysis multicomponent yoga is a feasible and safe form of relaxation and exercise among patients on maintenance dialysis. This pilot study demonstrates the feasibility and importantly supports the safety of conducting a parallel group randomized trial of intra-dialysis multicomponent yoga as a form of relaxation and exercise in maintenance dialysis patients.

3. Feasibility and safety of intradialysis yoga and education in maintenance hemodialysis patients-

Purpose- Patients with end-stage renal disease on maintenance hemodialysis are much more sedentary than healthy individuals. The purpose of this study was to assess the feasibility and safety of a 12-week intra-dialysis yoga intervention versus a kidney education intervention on the promotion of physical activity. Key recent advances in exercise studies have focused on the efficacy of novel intervention strategies across the CKD spectrum. These include high-intensity interval training, virtual reality gaming, intradialytic yoga, electrical stimulation of muscles, blood flow restriction training, and protocols combining exercise with nutritional supplementation. Research is also beginning to explore the role of prehabilitation for patients prior to dialysis and kidney transplantation.

Methods- Randomized participants by dialysis shift to either 12-week intra-dialysis yoga or an educational intervention. Intra-dialysis yoga was provided by yoga teachers to participants while receiving hemodialysis. Participants receiving the 12-week educational intervention received a modification of a previously developed comprehensive educational program for patients with kidney disease (“Kidney School”). The primary outcome for this study was feasibility based on recruitment and adherence to the interventions, and safety of intra-dialysis yoga. Secondary outcomes were to determine the feasibility of administering questionnaires at baseline and 12-weeks including the Kidney Disease-Related Quality of Life-36. Overall, the dose of intra-dialysis yoga was reasonable with a median practice of 22 minutes per dialysis session. The yoga protocol was designed to gradually increase the dose over 12 weeks. Given the low baseline physical function dialysis patients, a median of 60 minutes of mind-body practice a week may be sufficient to demonstrate therapeutic effects. Improving adherence as described above should effectively increase the dose of yoga.

Results- Among 56 eligible patients approached for the study, 100% (13 of 13) of participants completed 12-week intra-dialysis yoga and educational programs, respectively. There were no adverse events related to intra-dialysis yoga.  Preliminary data suggest that yoga may benefit patients with chronic diseases by improving quality of life, cardiovascular risk factors and disease and mood disorders. Potential mechanisms for yoga’s effect that may be distinct from health education alone include physical exercise, improved autonomic dysfunction (increase in parasympathetic and decrease in sympathetic nervous tone), improved mood,  stress reduction, increased self-efficacy, and contextual effects (attention from yoga teachers or group effect).

4. Effects of 6 months yoga program on renal functions and quality of life in patients suffering from chronic kidney disease-

Purpose- To study the effect of 6 months yoga program in patients suffering from chronic kidney disease (CKD). 

Methods- Fifty-four patients with CKD were studied and divided into two groups (yoga group and control group) to see the effect of yoga in CKD. Patients in the yoga group were offered yoga therapy along with other conventional treatment modalities, while the control group was only on conventional treatment. Subjects in the yoga group were trained to perform specific yogic asanas for at least 5 days a week for 40–60 min a day. Regular monitoring of blood pressure, renal function, requirement of a number of dialysis, and quality of life (QOL) indicators were done. Fifty patients (yoga – 25; control-25) completed 6 months follow-up

Results- In yoga group, a significant reduction of systolic and diastolic blood pressure, significant reduction in blood urea and serum creatinine levels, and significant improvement in physical and psychological domain of the World Health Organization QOL (as assessed by BREF QOL scores) were seen after 6 months. Post Study comparison between the two groups showed a statistically significant reduction of blood pressure, nonsignificant reduction in blood urea and serum creatinine, and significant improvement in physical and psychological domain of QOL in yoga group as compared to control group. For subjects in the yoga group, the need for dialysis was less when compared to the control group although this difference was statistically insignificant. Except for the inability of some patients to perform certain yogic asanas no adverse effect was found in the study. Six months yoga program is safe and effective as an adjuvant therapy in improving renal functions and QOL of CKD patients.

5. Study of effect of guided meditation on quality of life in patients of end stage renal disease (ESRD) on maintenance hemodialysis - a randomized controlled trial-

Purpose- Objective, to study effects of guided meditation on physical, emotional, and cognitive dimensions of well-being and quality of life in patients undergoing maintenance hemodialysis.

Methods- Collection of baseline and post intervention data in control and intervention groups on hemodialysis and studied the effect of Guided mediation provided for 6 weeks. Eighty patients (forty in control and intervention group each) were studied. Mean age was 51 years. There was a statistically significant difference in qualities of happiness and all measures of physical general wellbeing. There was a statistically significant difference in burden and effect of kidney disease as well as symptoms of kidney disease post intervention in Kidney Disease Quality of Life score. Qualitative analysis was studied by maintaining a diary of their subjective experiences related to listening music/guided meditation during the study period in which the feeling of peace and feeling inspired to manage the illness/ do regular work were the most common experiences (97.5%) reported by participants.

Results- Guided meditation resulted in statistically significant improvement in happiness, enthusiasm, inspiration, activeness, alertness, awareness, degree of stability, self-confidence, clarity of thoughts, control over anger, self-reflection intervention in the intervention group. It reduced perceived stress. It improved the burden and effect of kidney disease, symptoms of kidney disease and total Kidney Disease Quality of Life score. In qualitative dimensions of wellbeing (as emerging from analysis of results of diary), feeling of peace and feeling inspired to manage the illness/ continue regular work, clarity of thoughts, happiness, concentration, reduction of laziness, improved sleep pattern, reduction in anger among other psychological components.

6. Effect of yoga and naturopathy on liver, renal and cardiorespiratory functions of a patient with hepatic cirrhosis with portal hypertension and ascites: a case report-

Purpose- A 39-year-old, married man was diagnosed with hepatic cirrhosis with portal hypertension and ascites in February 2016. His symptoms as described by him began with generalized body weakness, breathlessness and sudden weight gain of 16 kg within 3 weeks. History of regular intake of alcohol since 7 years and tremendous family stress were present. Patient underwent conventional medication for 6 months and ayurvedic medications for 4 months. Integrated naturopathy and yoga therapies (INYTs) for 4 weeks along with Ayurveda and conventional medications. The results of this study showed a better reduction in body weight, body mass index, abdominal girth, systolic blood pressure and diastolic blood pressure along with improvement in breath holding time, hemoglobin level, liver function test and renal function test. It suggests that 4 weeks of INYT with Ayurveda and conventional medications was effective in patients with hepatic cirrhosis with portal hypertension and ascites.

Method- The patient was admitted to our hospital as an inpatient and underwent INYT for a period of 4 weeks. INYT includes naturopathic treatments like hydrotherapy, mud therapy, massage therapy and diet therapy and yoga practices like simple breathing exercises, pranayama and cyclic meditation.

Results- The results of this study suggest that INYT in combination with ayurveda and conventional medications were safe, feasible, well tolerated and effective in patients with hepatic cirrhosis with portal hypertension and ascites. The results of this study showed a better reduction in body weight, BMI, abdominal girth, SBP and DBP along with improvement in BHT, hemoglobin level, LFT and RFT. Stress is one of the most important factors that precipitate alcohol relapse, through a constellation of interrelated cognitive, emotional, physiological and behavioral mechanisms. Evidence suggests that yoga is useful for prevention, treatment and recovery from addiction by regulating stress and unhooking substance use impulses. According to naturopathy, there is only one cause of disease and only one way to cure the diseases, i. e. violation of nature (physical or mental or behavioral) is the cause of disease and returning to nature is the only way to cure the disease. A basic principle of naturopathy is “body heals itself” when you support and provide an opportunity by means of treating the patients as a whole using natural elements like water (hydrotherapy), mud (mud therapy), sun-cooked foods (fruits and vegetables), etc. Stress and inflammation play a role in the pathogenesis of hepatic cirrhosis, whereas yoga practice and the naturopathic treatments like massage and mud therapies were reported to reduce stress and inflammation. Similarly, hip bath is reported to be effective in improving the functions of abdominal organs, while kidney pack is reported to be effective in improving kidney functions (i. e. diuretic action that helps in reducing excessive fluid accumulation). Hence, considering both traditional and clinical concepts, the treatments have been provided to the patient in order to support the body and mind to heal itself. Stress is the subjective experience of negative emotional states coupled with physiological activation that often produces uncomfortable physical sensations, including muscle tension, elevated heart rate and blood pressure and gastrointestinal distress. A marked cardiorespiratory impairment is known to develop in patients with hepatic cirrhosis. As described by the patient, he was having tremendous family stress and was consuming alcohol regularly for the past 7 years. In the baseline assessment, both SBP and DBP were also found to be higher, while BHT (one of the variables used to measure the pulmonary function) was very lower in the patient. The results of this study showed a better reduction in both SBP and DBP along with a better increase in BHT. It suggests that the INYT is effective in improving cardiorespiratory functions of patients with hepatic cirrhosis with portal hypertension and ascites. It might be attributed to the practice of yoga that is known to reduce stress and improve respiratory muscles. Endothelial injury/dysfunction, hepatocyte degeneration and necrosis and inflammatory cell infiltration are observed in the pathogenesis or development of hepatic cirrhosis that leads to the impairment of liver functions and serum protein levels. The results of this study showed a better improvement in LFT and serum protein levels after INYT. It suggests that 4 weeks of INYT is effective not only in improving liver functions but also in restoring the serum protein levels in patients with hepatic cirrhosis. And, it indicates that INYT might play a role in controlling the development of hepatic cirrhosis. Because, practice of yoga was reported to improve endothelial dysfunctions and reduce the inflammation, and the naturopathic treatments like massage and mud therapies were also reported to reduce stress and inflammation in inflammatory diseases. Diet that was provided to this patient was in combination of various fruits, diuretic juices, low fat and low protein which might have played a vital role in reducing the workload of the liver and in providing the micronutrients that were depleted by chronic alcohol consumption.

7. The role of mind-body interventions in pre-dialysis chronic kidney disease and dialysis patients - A systematic review of literature-

Purpose- With the rise in complementary medicine usage, mind-body interventions (MBI), encompassing therapies like yoga and music therapy, have been gaining interest. The use of MBI in non-chronic kidney disease (CKD) patients have demonstrated efficacy for ameliorating pain, stress and anxiety symptoms. As CKD patients often suffer from these symptoms, MBI may serve as potential adjunctive therapies. This review aimed to summarize the studied indications of MBI among CKD patients.

Methods- A systematic review was performed in Medline®, Embase®, Scopus®, CINAHL®, CENTRAL® and PsycInfo® in accordance with the PRISMA and SWiM checklists. Randomized controlled trials (RCTs) which evaluated the use of MBI among adult CKD patients were included. The efficacy of each MBI was determined by reduction in symptoms severity scores. Music therapy (n = 11), relaxation therapy (n = 9) and spiritual therapy (n = 6) were the most well studied MBIs. Frequently studied indications for MBIs were anxiety symptoms (n = 12), pain (n = 7) and depressive symptoms (n = 5). Music and spiritual therapies were shown to reduce 8.06-43.5 % and 36.1-41.1 % of anxiety symptoms respectively. For pain relief, music (41.8 %-61.5 %) and yoga therapies (36.7 %) were shown to be effective for reduction of pain. Lastly, spiritual therapy was shown to reduce depressive symptoms by 56.8 %. No adverse effects were reported for any MBI.

Results- Music therapy, relaxation and spiritual therapies are more well-studied MBIs which were shown to reduce anxiety, depressive symptoms and pain in CKD patients. Larger RCTs are required to confirm the efficacy and safety of promising MBIs.

8. Effect of yoga on physical and psychological outcomes in patients on chronic hemodialysis

Purpose- Patients on chronic hemodialysis suffer from a myriad of problems associated with dialysis including increased cardiovascular disease, deconditioning, fatigue, sleep disturbances, anxiety and depression, and decreased health related quality of life. Yoga has been reported to have positive effects on distress and functional performance in patients with chronic diseases. The effect of yoga in patients on chronic hemodialysis is unknown. For the purpose of this study, papers were reviewed to determine the effect of intradialysis yoga on distress and functional performance in patients undergoing chronic hemodialysis.

Methods- This integrative review examined studies published in Pubmed, CINAHL and PsychINFO. The search terms included: yoga, hemodialysis, dialysis.

Results- Two RCTs met the criteria. Yoga showed improvement in several outcomes including: quality of life, pain, fatigue, sleep disturbance, physical function as well as a number of biochemical variables. Findings from these studies suggest that yoga might benefit patients on HD by improving physical and psychological outcomes. Yoga has potential utility as a complementary and alternative therapy for chronic diseases and can help patients on HD improve a number of health outcomes.

Summary- Yoga (intradialytic or other forms), Ayurvedic medicines (mud therapies and Ayurvedic/Vegetarian diet), guided meditation, music and hip baths have all been found to be promising as effective treatments for liver dysfunction. Many benefits have been show such as; increased exercise capacity, increased protein synthesis, increased microvascular function, increased diameter of cephalic vein, increased diameter of radial artery, increased handgrip strength, improved gait speed, number of stunned cardiac segments was down, improved level of activity, high level of satisfaction with intervention, increased power and increased muscular strength, improving quality of life, decreased risk of cardiovascular risk factors, improved autonomic dysfunction (increase in parasympathetic and decrease in sympathetic nervous tone), improved mood, stress reduction, increased self-efficacy, and contextual effects (attention from yoga teachers), significant reduction of systolic and diastolic blood pressure, significant reduction in blood urea and serum creatinine levels, need for dialysis was less, significant improvement in happiness, enthusiasm, inspiration, activeness, alertness, awareness, degree of stability, self-confidence, clarity of thoughts, control over anger, self-reflection intervention in the intervention group. It reduced perceived stress. It improved the burden and effect of kidney disease as well as the symptoms of kidney disease. Feeling inspired to manage the illness/ continue regular work, clarity of thoughts, concentration, reduction of laziness, improved sleep pattern. a better reduction in body weight, BMI, abdominal girth, SBP and DBP along with improvement in BHT, hemoglobin level, LFT and RFT. 

References:

1. Wilkinson TJ, McAdams-DeMarco M, Bennett PN, Wilund K; Global Renal Exercise Network. Advances in exercise therapy in predialysis chronic kidney disease, hemodialysis, peritoneal dialysis, and kidney transplantation. Curr Opin Nephrol Hypertens. 2020 Sep;29(5):471-479. doi: 10.1097/MNH.0000000000000627. PMID: 32701595; PMCID: PMC7526394.

2. Keenan, J. S. (2022, November 29). Yoga can serve as relaxation, intra-dialysis exercise for patients on maintenance dialysis. Healio. https://www.healio.com/news/nephrology/20221129/yoga-can-serve-as-relaxation-intradialysis-exercise-for-patients-on-maintenance-dialysis 

3. Birdee GS, Rothman RL, Sohl SJ, et al. Feasibility and safety of intradialysis yoga and education in maintenance hemodialysis patients. J Ren Nutr 2015; 25:445–453

4. Pandey RK, Arya TV, Kumar A, Yadav A. Effects of 6 months yoga program on renal functions and quality of life in patients suffering from chronic kidney disease. Int J Yoga. 2017 Jan-Apr;10(1):3-8. doi: 10.4103/0973-6131.186158. PMID: 28149061; PMCID: PMC5225742.

5. Vaishnav BS, Hirapara JJ, Shah MK. Study of effect of guided meditation on quality of life in patients of end stage renal disease (ESRD) on maintenance hemodialysis - a randomized controlled trial. BMC Complement Med Ther. 2022 Sep 9;22(1):238. doi: 10.1186/s12906-022-03717-8. PMID: 36085065; PMCID: PMC9461254.

6. Revadi, Shreya S., Kavitha, V. and Mooventhan, A.. "Effect of yoga and naturopathy on liver, renal and cardiorespiratory functions of a patient with hepatic cirrhosis with portal hypertension and ascites: a case report" Journal of Complementary and Integrative Medicine, vol. 15, no. 4, 2018, pp. 20170098. https://doi.org/10.1515/jcim-2017-0098

7. Chu SWF, Yeam CT, Low LL, Tay WY, Foo WYM, Seng JJB. The role of mind-body interventions in pre-dialysis chronic kidney disease and dialysis patients - A systematic review of literature. Complement Ther Med. 2021 Mar;57:102652. doi: 10.1016/j.ctim.2020.102652. Epub 2020 Dec 26. PMID: 33373760.

8. KauricKlein Z. Effect of yoga on physical and psychological outcomes in patients on chronic hemodialysis. Complement Ther Clin Pract. 2019 Feb;34:41-45. doi: 10.1016/j.ctcp.2018.11.004. Epub 2018 Nov 7. PMID: 30712744.