Nephroprotective Effect of Long-Term Integrated Yoga and Plant-Based Diet in a Patient Suffering from Chronic Kidney Disease—A Single Case Report

Abstract

Chronic kidney disease (CKD) is the deterioration of renal parenchyma eventually advancing to end-stage renal disease. About one out of three individuals with type 2 diabetes (T2D) and one out of five with hypertension have CKD. Integrated yoga and naturopathy (IYN) incorporates diverse therapeutic approaches that manage hypertension, diabetes, and obesity including CKD. A 60-year-old female homemaker pre-diagnosed with CKD and T2D visited our outpatient department with complaints of swelling in both legs for the past 3 months, bilateral knee pain for the past 6 months, and a gradual increase in weight for the past 10 years. She underwent IYN (including yoga sessions and a plant-based diet) for 7 months and 20 days. The estimated glomerular filtration rate (eGFR), serum creatinine, uric acid levels, postprandial blood glucose (PPBG), glycosylated hemoglobin (HbA1c), and C-reactive protein (CRP) marker were assessed before and 6 months after intervention. The case report showed improved eGFR and reduced serum creatinine, uric acid, PPBG, HbA1c, and CRP levels. Yoga and naturopathy interventions are feasible, cost-effective, and easy to adhere to improve kidney-related functions among individuals with CKD.

Background

Chronic kidney disease (CKD) is the persistent destruction of the parenchyma of the kidney, resulting in a gradual deterioration of the functions of nephrons that can eventually progress to end-stage disease. It is characterized by a glomerular filtration rate (GFR) of less than 60 mL/(min·1.73 m²) or the existence of one or more kidney dysfunction markers (including urinary albumin excretion).^1,2 CKD affects 9.5% of the global population, reported to exceed 850 million, whereas South Asia reports 14% of adults with CKD. It is estimated that 143–234 million people are at risk of kidney damage.^3,4 The mortality rate (due to kidney failure) increased to 38% in India. By 2040, CKD is projected to be the fifth leading cause of years of life lost worldwide. Approximately one out of three individuals with type 2 diabetes (T2D) and one out of five with hypertension have CKD. This suggests that controlling T2D and cardiovascular disease could reduce the rising prevalence of CKD.^5,6 The influencing risk factors encompass nonmodifiable (age, gender, race, ethnicity, and family background) and modifiable risk factors (obesity, diabetes mellitus, hypertension, cardiovascular disease, sympathetic overactivity, history of acute kidney injury, excess use of nephrotoxins, and drug abuse). ⁷ Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, sodium glucose co-transporter inhibitors, statin therapy, glucagon-like peptide receptor agonists, mineralocorticoid receptor antagonists, and endothelin receptor antagonists failed to achieve effective blood pressure and glucose control. Thus, a comprehensive approach is a timely need to address these risk factors in preventing and mitigating the impact of CKD on renal function. Consistent monitoring and lifestyle changes (plant-based diet, physical activity, smoking cessation, and weight management) are the crucial components of effective management and prevention approaches. ⁸

Integrated yoga and naturopathy (IYN) is a comprehensive therapeutic approach that emphasizes the principles and practices of yoga and naturopathy to address various disease conditions. ⁹ IYN has been documented to be beneficial in conditions such as hypertension, hypothyroidism, obesity, and diabetes mellitus.^10–13 Studies on yoga and meditation have reported their beneficial effects on CKD by improving overall well-being, stress management, and physical functioning. ¹⁴ A previous case study documents the impact of naturopathy intervention in the management of CKD by decreasing creatinine levels. ¹⁵ However, there is a lack of studies that report the long-term effect of IYN on GFR in individuals with CKD. This case report intended to study the impact of long-term IYN in a patient with CKD.

Patient Information

A 60-year-old female homemaker presented to our outpatient department with complaints of swelling in both legs for the past 3 months, bilateral knee pain for the past 6 months, and a gradual increase in weight for the past 10 years. Swelling and pain are aggravated by standing for a long time, climbing stairs, and walking and get relieved by rest. She was diagnosed with CKD (in the year 2023), and she is a known case of T2D, obesity, and dyslipidemia (for the past 10 years) for which she is under regular oral medications (Tab. atorvastatin 10 mg [0–0–1], tab. vildagliptin 50 mg and metformin hydrochloride 500 mg [1–0–1], tab. cholecalciferol 60k [1–0–0, weekly once], tab. esomeprazole magnesium 40 mg [1–0–0]). She had no previous surgical history. She has a family history of T2D. Her obstetric history includes gravida—7, parity—3, live birth—3, and abortion—4. She had a surgical history of hysterectomy at 50 years. She followed a mixed diet with a personal history of sound sleep, increased appetite, irregular bowel movements, and a normal frequency of micturition (diurnal—3–4 times and nocturnal—1 time). Her habits include intake of tea/coffee twice a day for the past 20 years. She is allergic to almonds and peanuts and sensitive to sun exposure.

Clinical Findings

On general physical examination, she had a normal gait, was well oriented with an active physical attitude, and was obese, and there were no signs of pallor, icterus, cyanosis, clubbing, and lymphadenopathy. While performing the systemic examination, inspection revealed that there was hyperpigmentation around the neck and armpit; there was no pain, tenderness, or organomegaly noted on palpation; and no abnormalities were noted on percussion. Auscultation revealed normal S1 and S2 heart sounds and normal vesicular breath sounds. There were no motor or sensory deficits with normal superficial and deep reflexes. Her vitals include a blood pressure of 136/88 mmHg, pulse rate of 85 bpm, and respiratory rate of 20 cpm.

Timeline

The patient timeline is represented in Figure 1.

FIG. 1.

Timeline. A detailed participant timeline is demonstrated.

Diagnostic Assessment

Her hematology reports dated (July 24, 2023) revealed estimated GFR (eGFR) (56.73 mL/[min·1.73 m²]), serum creatinine (1.1 mg/dL), serum uric acid (6.6 mg/dL), postprandial blood glucose (PPBG) levels (125 mg/dL), glycosylated hemoglobin (HbA1c) (6.7%), and C-reactive protein (CRP) (6.21 mg/L). A qualified lab technician drew 5 mL of venous blood using proper antiseptic procedures via venipuncture. Blood samples were collected in a fed state, and all the tests were conducted at a recognized laboratory before and after the intervention period. The eGFR levels were calculated using Chronic Kidney Disease Epidemiology Collaboration (CKD EPI) formula.

Therapeutic Intervention

Following a detailed case history taking and consultation, an integrated treatment plan incorporating yoga and a plant-based diet (PBD) was devised for the patient, as mentioned in Tables 1 and 2. The details of this protocol were thoroughly explained, and the patient provided informed consent. The patient received regular yoga sessions at home by one of the investigators and a plant-based diet (4–5 days/week) for 7 months and 20 days. The therapies were well tolerated, and the patient remained stable throughout the treatment period, with no reported adverse effects.

Table 1.

Details, Timing, Duration, and Frequency of Yoga Intervention

Yoga intervention	Frequency	Morning (5.30–6.30 am)
Starting prayer	1	2 mins
Pawanamuktasana series 1	5	8 mins
Breathing practices (hand in and out breathing, hand stretch breathing, ankle stretch breathing)	10	8 mins
Asanas:	2	30 mins
(Tadasana, Ardhakatichakrasana, Katchakrasana, Trikonasana, Parivrita trikonasana, Veerabadrasana, Parshvakonasana, Ardha uttanapadasana, Uttanapadasana, Ardha pawanamuktasana, Sedhubandasana, Bhujangasana, Triyaka bhujangasana, Vyagharasana, Marjariasana, Vakrasana, Janusirsasana)
Pranayama:	9	10 mins
Nadi shodhana pranayama
Bhramari pranayama
Closing prayer	1	2 mins

Table 2.

Menu Plan, Timing, and Quantity of Plant-Based Diet

Timings	Diet	Quantity
6.30 am (empty stomach)	½ lemon + water (or)	150 mL
	1 amla + water
8.00 am	Hibiscus tea	50 mL
8.30–9.00 am	Sprouted green gram	50 g
	Soaked groundnut +	20 g
	grated ridge gourd and snake gourd + salt + pepper	100 g
	Nuts	20 g
	Weekly once—sprouted green gram +	50 g
	dates +	4 Nos
	grated coconut +	2 tsp
	water melon and muskmelon	250 g
11.00 am	Nuts (or)	10 g
	boiled chickpeas	100 g
1.00–1.30 pm	1 cup rice +boiled vegetables + rasam + curd (with coconut milk)	100 g
		200 g

Vegetables to be included: bottle gourd, radish, broad beans, ladies finger, ridge gourd, snake gourd, bitter gourd, knol khol, capsicum, ash gourd, yellow pumpkin, spinach, and mushroom.

Fruits to be included: apple, guava, pineapple, pomegranate, grapes, prunes, cranberry, orange, jamun, and pears.

Pulses to be included: toor dhal, moong dhal, green gram, and horse gram.

Nuts to be included: pumpkin seeds, cucumber seeds, walnuts, and flax seeds.

Follow-up and Outcomes

The patient was provided with intervention for 7 months and 20 days. Pre- and post-assessments were taken before and after the intervention period. The outcome variables showed improvement in eGFR levels and reductions in the serum creatinine, serum uric acid, PPBG, HbA1c, and CRP levels, as detailed in Table 3 and Figure 2. The intervention was well tolerated and reported no adverse effects.

FIG. 2.

Schematic representation of pre- and post-assessment data of the outcome variables.

Table 3.

Pre- and Post-Assessment Data of the Outcome Variables

Outcome variable	Pre-assessment data	Post-assessment data
eGFR	56.73 mL/(min·1.73 m2)	83.49 mL/(min·1.73m2)
Serum creatinine	1.1 mg/dL	0.76 mg/dL
Serum uric acid	6.6 mg/dL	5.2 mg/dL
PPBG	125 mg/dL	99 mg/dL
HbA1c	6.7%	6.3%
CRP	6.21 mg/L	3.38 mg/L
4.00 pm	Cinnamon tea	50 mL
6.00 pm	Fruit bowl	200 g

CRP, C-reactive protein; eGFR, estimated glomerular filtration rate; HbA1c, glycosylated hemoglobin; PPBG, postprandial blood glucose.

Discussion

The results showed an increase in the eGFR along with a decrease in serum creatinine, uric acid, PPBG, HbA1c, and CRP levels. This implies a beneficial impact of IYN in patients with CKD. These favorable results might be achieved due to the following mechanism of action.

Research has indicated that elevated sympathetic tone is potentially involved in the progression of CKD, contributing to hypertension, and leading to end organ damage. Evidence suggests that yoga reduces sympathetic tone and improves parasympathetic tone, thereby reducing metabolic rate. Yoga, in combination with conventional treatment, resulted in a significant reduction in blood urea and serum creatinine values over a period of 6 months by improving the excretory mechanism that resulted in the normalization of water and electrolyte balance. ¹⁶

A daily 30-min practice of hatha yoga for 4 months resulted in a significant reduction in oxidative stress markers (malondialdehyde, protein oxidation, and phospholipase A2 activity) and an increase in antioxidant activity (superoxide dismutase and catalase activities) in patients with CKD undergoing hemodialysis. ¹⁷

Pranayama techniques stretch lung tissue, stimulating inhibitory signals through the activation of slowly adapting receptors and hyperpolarizing currents. These signals, originating from the cardiorespiratory region, engage the vagus nerves to synchronize neural components in the brain. This process induces shifts in the autonomic nervous system, reducing sympathetic activity and enhancing parasympathetic dominance. Achieving the balance between the sympathetic and the parasympathetic components reduces inflammation and improves outcomes in CKD and cardiovascular disease.^18,19

Generally, a PBD consists of alkali-producing foods that have a negative potential renal acid load. Many of these foods contain citrate and malate, which are converted into bicarbonate. Research has shown that oral bicarbonate supplementation or increased intake of alkali-rich foods can reduce the incidence of end-stage kidney disease.

PBD has a lower dietary acid load that reduces intraglomerular pressure and preserves kidney function. PBD improves the sensitivity of insulin, reduces blood pressure, and promotes weight loss, thereby managing T2D, hypertension, and obesity, which are the primary contributors of CKD. PBD possesses anti-inflammatory and antioxidant properties that can mitigate the oxidative stress and inflammation linked to CKD progression. Increasing the fiber intake (PBD) contributes to a shift in the gut microbiome that is associated with reduced uremic toxins and reactive oxygen species, thereby promoting bacterial nitrogen trapping and shorter colonic transit time.^20–22

Comparing the results of the previous study,^14,15 this case report also confers the beneficial result in patients with CKD. The long-term follow-up and consistency in adhering to the interventions and remarkable changes in the eGFR are the strengths of this case report. The limitation of the study is that the findings of this case report cannot be generalized for all individuals with CKD. Future studies should focus on conducting randomized controlled trials with larger sample sizes to generalize the effectiveness of IYN among patients with CKD.

Conclusions

Yoga and PBD are feasible, cost-effective, and easy to adhere for improving renal function among patients with CKD. Thus, IYN into conventional management might improve the likelihood of CKD progression and increase life satisfaction.