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OVERVIEW OF CHRONIC KIDNEY DISEASE Chronic kidney disease (CKD) affects over 26 million adults in the United States and is defined as 3 or more months of either (1) histopathologic or functional evidence of kidney damage, or (2) a glomerular filtration rate less than 60 mL/min/1.73 m2. CKD is classified into five stages based on the degree of functional impairment, as inferred from estimations of glomerular filtration rate. CKD can be caused by numerous underlying processes. In general, causes can be grouped into glomerular diseases (such as diabetic nephropathy or lupus nephritis), vascular diseases (such as hypertension), tubulointerstitial diseases (such as obstructive uropathy), and cystic diseases. The most common causes are diabetes mellitus and hypertension, which together account for over two thirds of cases. PATHOPHYSIOLOGY Irrespective of the primary renal disease, the kidney initiates a compensatory response to nephron loss that is initially adaptive but ultimately causes further loss of function. Thus the progression of CKD depends in part on mechanisms that are independent of the inciting disease process. In particular, loss of a subset of nephrons results in compensatory hyperfiltration and hypertrophy of the remaining functional nephrons, an effect likely mediated by angiotensin II, aldosterone, endothelin, and other hormones. The resulting intraglomerular hypertension, however, eventually becomes maladaptive, inflicting damage to the remaining nephrons and thereby causing a further decline in overall filtration. In the glomerulus, podocyte (visceral epithelial cell) foot process effacement and denudation may lead to a breakdown of the protein filtration barrier and glomerulosclerosis. The ensuing proteinuria is thought to further promote kidney failure by exerting toxic effects on the tubules. In addition, mesangial cells respond to the increased pressure with proliferation and production of increased extracellular matrix; these changes stimulate inflammation and cellular infiltration of the mesangium and tubulointerstitium, leading to tubulointerstitial fibrosis. A significant number of nephrons must be lost before these maladaptive changes are seen, and the exact quantity varies between species and individuals. In rats, for example, one and 5/6 nephrectomy must be performed to create a model of progressive renal insufficiency. In humans, it is well-known that donation of one entire kidney does not generally result in loss of overall renal function. In those individuals who do lose enough functional renal mass to experience the maladaptive effects of hyperfiltration, the rate of further functional decline is also variable, depending on the primary inciting factor, patient age, and possibly genetic factors. ASSESSMENT OF RENAL FUNCTION The serum creatinine concentration should be used to estimate the creatinine clearance or GFR (eGFR), which can be accomplished using the Cockcroft-Gault formula or the modification of diet in renal disease (MDRD) study equation, respectively. Current guidelines recommend that serum creatinine concentration be measured at least once per year in patients with CKD. The frequency should be increased in those with an eGFR <60 mL/min/1.73 m2, loss of >4 mL/min/1.73 m2 per year of eGFR, or with risk factors for progression (high level of proteinuria, hypertension, diabetes mellitus). Patients should be referred to a nephrologist when the eGFR falls below 30 mL/min/1.73 m2, or sooner if the primary care physician is unable to carry out a treatment plan for CKD. COMPLICATIONS AND MANAGEMENT Patients with CKD are typically asymptomatic until the disease process becomes advanced. Thus it is important to screen for CKD and its complications in high-risk patients, such as those with diabetes mellitus and/or hypertension, so that treatment can be initiated at an early stage. Hypertension. Hypertension is both a cause and consequence of progressive chronic kidney disease. It is a cause because elevated arterial pressures are transmitted to the glomeruli of the remaining nephrons, exacerbating hyperfiltration and accelerating further nephron loss. It is also a consequence because, as nephron loss progresses, there is ongoing secretion of angiotensin II and impaired excretion of excess sodium and water. Thus more than 75% of patients with CKD suffer from hypertension. Blood pressure must be routinely measured in all patients, and hypertension must be treated to slow nephron loss. Blood pressure should be kept at 130/80 mm Hg or less, and the mainstays of treatment are medications that block the renin-angiotensin-aldo-sterone system, including ACE inhibitors and ARBs. These agents preferentially dilate efferent arterioles, lowering intraglomerular pressure. Because of this partial reversal of glomerular hyperfiltration, there is an expected and acceptable 30% increase in serum creatinine; however, providers should carefully monitor patients for both acute declines in eGFR and hyperkalemia. Diuretics are often needed as well, especially as more advanced disease leads to greater retention of sodium and water. In general, at an eGFR <30 mL/min/1.73 m2, loop diuretics are more effective than thiazide diuretics. Patients should also be strongly encouraged to maintain a low-salt diet. Proteinuria. Proteinuria is a marker of glomerular injury, but it is also understood to contribute to CKD progression. In particular, proteins that are filtered in the glomerulus are reabsorbed in proximal tubule cells, where they trigger inflammation, apoptosis, and fibrosis. In addition, abnormal filtration of growth factors and cytokines also promotes tubular injury. Thus a reduction in proteinuria has been associated with a slower progression of chronic kidney disease, particularly among patients with diabetic disease. Proteinuria must be regularly assessed in all patients. In nondiabetics, screening with urine dipstick is acceptable, but if positive, a spot urine protein : creatinine ratio should be performed for quantification. A 24-hour urine collection for protein can be performed; however, a spot sample is typically adequate and is easier for the patient. In diabetics, regular screening for microalbuminuria should be performed early in the disease course. ACE inhibitors and ARBs have been shown to reduce proteinuria, likely because of the reduction in intraglomerular pressure. Studies in diabetic patients have shown that these drugs reduce proteinuria and slow the decline of eGFR independent of their effect on systemic blood pressure. Bone Disease. Renal disease also leads to numerous morphologic changes in bone, a group of phenomena collectively known as renal osteodystrophy. This disorder encompasses a spectrum of disease with both high bone turnover (osteitis fibrosa cystica) and low bone turnover (adynamic bone disease and osteomalacia). Osteitis fibrosa cystica, a high turnover disease, reflects secondary hyperparathyroidism and is associated with bone pain and an increased risk of fracture. High PTH levels are often seen once the eGFR declines to less than 60 mL/min/1.73 m2 (stage 3 CKD), and they are invariably seen when eGFR is less than 30 mL/ min/1.73 m2 (stage 4 CKD). High PTH levels initially occur because of decreased renal production of 1,25(OH)2D, the activated form of vitamin D, which results from both a reduction in renal mass and impaired renal excretion of phosphate. The decline in 1,25(OH)2D stimulates PTH secretion and, moreover, causes a reduction in intestinal reabsorption of calcium, which further stimulates PTH release. Initially, the high levels of PTH maintain serum phosphate and calcium concentrations within normal range, at the expense of causing bone disease. As renal dysfunction progresses, however, hyperphosphatemia ensues. In addition, hypocalcemia eventually occurs, both because of the decline in 1,25(OH)2D levels and because of formation of soluble calcium phosphate complexes. Skeletal resistance to PTH, which remains chronically elevated, also appears to play a role. In patients with stage 3-5 CKD, serum concentrations of PTH, phosphate, and calcium should be checked regularly. According to current guidelines, the goal PTH levels for stage 3 CKD are 35 to 70 pmol/L, for stage 4 CKD are 70 to 110 pmol/L, and for stage 5 CKD are 150 to 300 pmol/L. Goal serum phosphate levels for stages 3 and 4 CKD are 2.7 to 4.6 mg/dL, and for stage 5 CKD are 3.5 to 5.5 mg/dL. To achieve these levels, hyperphosphatemia is typically addressed first using a low phosphorous diet and phosphate binders. Either calcium or noncalcium containing binders may be used, with the choice sometimes depending on the patient’s serum calcium concentration. Vitamin D (25-OH) levels should also be checked, and if levels are below 30 µg/mL, supplemental ergocalciferol may be offered. If PTH levels remain elevated despite these measures, active vitamin D analogues (such as calcitriol) may be used in lieu of ergocalciferol; however, these agents may cause marked elevation of serum phosphate and calcium levels, which must continue to be carefully monitored. In patients with more advanced disease, calcimimetics (i.e., cinacalcet) may be used, although they are only approved for those receiving dialysis. Calcimimetics bind to the calcium sensing receptor on the parathyroid glands, suppressing PTH release, but they are associated with an increased risk of hypocalcemia. If PTH levels are oversuppressed, patients can develop adynamic bone disease, which is also associated with increased risk of fracture. This disorder is becoming increasingly common as vitamin D analogues are more widely used to suppress PTH. If the PTH level falls below 100 pmol/L, the risk of adynamic bone disease is high, and dosages of vitamin D analogues and calcium-based phosphate binders should be reduced. Finally, osteomalacia, another form of low bone turn-over disease, can be seen in some patients due to vitamin D deficiency or aluminum toxicity. With the near elimination of aluminum-based binders in clinical practice, however, aluminum toxicity is now uncommon. The specific type of bone disease can be definitively diagnosed with bone biopsy, which is not routinely performed in clinical practice. Instead, the presence of bone disease is typically inferred from abnormal PTH levels. Acidosis. Once GFR declines to 40 to 50 mL/ min/1.73 m2, patients are not able to excrete their daily acid load. The remaining functioning nephrons have maximized their ammonium excretion, and excretion of titratable acids may also be reduced because of the dietary restriction of phosphate and use of phosphate binders. The result is metabolic acidosis with a positive anion gap, which is usually discovered as a low serum bicarbonate level on a routine assessment of serum chemistries. Current guidelines recommend that serum bicarbonate be checked annually in patients with stage 3 CKD and every 3 months in patients with stage 4 or 5 CKD. It is recommended that serum bicarbonate concentrations be maintained at 22 mEq/L or greater. Oral bicarbonate replacement can be used to achieve this goal. Anemia. CKD leads to normocytic anemia due to inadequate renal production of erythropoietin. Anemia is sometimes seen in stage 3 CKD and is almost always seen in stage 4 CKD. Current guidelines recommend that hemoglobin levels be measured annually in any patient with CKD. In males with hemoglobin less than 13 g/dL and females with hemoglobin less than 12 g/dL, further workup should be performed, including a complete blood count, reticulocyte count, and an assessment of iron stores. Relative iron deficiency is common and contributes to the decreased production of red cells. One reason for iron deficiency is that the inflammatory cytokines released in CKD promote secretion of hepcidin, which blocks iron absorption from the GI tract and iron release from macrophages. In general, erythropoiesis-stimulating agents are used to maintain a hemoglobin level of 11 to 12 g/dL. The target should not exceed 13 g/dL. In patients receiving this treatment, iron stores should be assessed and replenished as needed to avoid apparent erythropoietin resistance. Oral iron supplements, such as iron sulfate or iron gluconate, are commonly given. If patients are resistant to these supplements because of impaired intestinal absorption, intravenous iron preparations may be used instead. Cardiovascular Disease. Cardiovascular disease is the leading cause of death among patients with chronic kidney disease, and it affects 40% of dialysis patients compared with 10% of the general population. Patients with CKD are more likely to have classic risk factors for cardiovascular disease, such as hypertension, diabetes mellitus, and hyperlipidemia. CKD itself, however, also appears to be an independent risk factor for CVD, and recent studies have shown a strong correlation between declines in eGFR and increased cardiovascular events. Numerous factors are responsible for this association. Vascular calcification appears to result from the use of calcium-based phosphate binders and vitamin D analogues. It may affect the intimal layer, leading to atherosclerotic plaques, and/or the medial layer, leading to vessel stiffening. The inflammation and secondary hypertension associated with CKD also accelerate vascular disease. In addition to increasing the risk for cardiovascular disease, CKD also increases the risk of left ventricular hypertrophy by causing hypertension, anemia, and hypervolemia. The prevalence of left ventricular hypertrophy is much higher among dialysis patients than the general population. Modification of cardiovascular risk factors such as smoking, hyperlipidemia, and hypertension should remain a primary focus of therapy. Even after kidney disease becomes more advanced, many patients die from cardiovascular disease before ever reaching end stage renal disease. Hyperkalemia. Renal excretion of potassium does not become significantly impaired until stage 4 CKD; however, a potassium rich diet or use of ACE inhibitors/ARBs can lead to hyperkalemia at earlier stages. A low potassium diet (<50 mEq/day) may be instituted as a preventive measure. In addition, treating metabolic acidosis will lower serum potassium levels, and loop diuretics may be used to promote urinary excretion of potassium. Dialysis may be required if hyperkalemia becomes refractory to medical management. Volume Overload. Overt symptoms of volume overload, such as peripheral and pulmonary edema, do not typically occur until stage 5 CKD but can be precipitated in earlier stages by increased salt intake or coexisting congestive heart failure. These symptoms can generally be treated with sodium restriction and additional diuretics. Uremia. As renal dysfunction becomes very advanced, the retention of toxic substances in the general circulation can lead to numerous abnormalities that are together known as uremia. In general, the term is used to describe the effects of those retained toxins that have not been identified or are poorly understood. Signs and symptoms of uremia include loss of appetite, weight loss, fatigue, altered mental status, peripheral neuropathies, nausea, vomiting, pruritus, and platelet dysfunction. Although uremia is associated with an elevated blood urea nitrogen (BUN) concentration, BUN itself is not felt to be the cause of uremia. ADDITIONAL CONSIDERATIONS It is essential that renally cleared medications be dosed based on eGFR. Furthermore, drugs that may precipitate an acute decline in renal function, such as nonsteroidal antiinflammatory drugs should be avoided. Careful consideration must be given when administering iodinated contrast due to the risk of acute renal failure. In addition, gadolinium-based contrast should be used judiciously in patients with stage 4 or 5 CKD because of the increased risk of nephrogenic systemic fibrosis. END STAGE RENAL DISEASE Ultimately, a small proportion of patients with CKD will progress to end-stage renal disease (ESRD), defined as the need for dialysis therapy or kidney transplantation. The rate of progression, however, is highly variable across patients. Dialysis is typically initiated when the eGFR falls below 10 mL/min/1.73 m2; however, there are numerous acute indications as well, which include refractory hyperkalemia, volume overload, and uremia. In most patients, preemptive kidney transplantation is preferred over ongoing dialysis because the long-term survival is significantly better. Compared with dialysis patients on the transplant list, patients who receive a kidney transplant have an initial increase in mortality; however, at 4 months post-transplant the risk of death is equal between the two groups, and thereafter transplanted patients have a 68% lower risk of mortality compared with patients on dialysis. The survival benefit is particularly robust among patients with diabetes.

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Now that we know that the spine is built by one vertebra above the other with it's healthy curves and properties, is time to talk about how the spine integrates with the other parts of the body. The measure in which we realize this and make it ours, we will transform our yoga practice (in case we have one) into a more mature practice, and most importantly our daily life. The spine is surrounded by many muscles and ligaments on different layers. These muscles relate the spine to the pelvis, the legs, the head, the shoulders, the arms, the chest, the groins, and the abdomen (as you can see, with the whole body). Their proper use will lead to a healthy, fluid and beautiful posture in life (I am not refering to an asana) and will spare you from future suffering. The knowledge of these muscles will take you to flex or extend your pelvis, to arch or bend your spine, to turn your shoulders, yo widen the chest, or to ground your sitting bones and grow up like a tree rooting in the earth. In between the vertebral bodies, it's possible to find some sort of cushions which pad the contact between them called intervertebral disks. When weight and pressure are too much or the discs, the semisolid content of them spills out pressing the spinal nerves and causing an awful lot of pain. The most vulnerable parts of the spine are only protected by muscles. The cervical vertebrae which "only" carry around 5 kg are surrounded by fewer and thinner muscles than the lumbar which has the whole weight of the upper body, this is the reason why inverted postures, like head balance and shoulder balance, in which the weight of the body is very much on the head and neck should be approached with lots of care so as not to damage the cervical region permanently. The lumbar portion of the spine is protected at the front by a group of muscles called the "abdominal muscles", which are mainly three: the Rectus abdomini, the Transversus abdomini, and Obliques. The back of the lumbar is protected by the Latissimus dorsi and part of the muscular system called the "Erector spinae" which is in charge of keeping the spine upright. (See picture A) Picture A. The many muscles of the back. There are very many muscles that work in the spine, but the ones we will focus on for the time being are the abdominal muscles, the Latissimus dorsi, the erector muscles, and the Iliopsoas. The Iliopsoas is a key postural muscle, it a flexor of the pelvis, that means it tilts your pelvis into the forwardbend position. It is composed by two smaller muscles (Iliacus and Psoas major). The Iliacus starts on the pelvic crest and ends on the outer edge of the femur head (lesser trochanter). The Psoas major starts at the transverse processes, bodies and disks of the lumbar vertebrae and the 12th toracic vertebra, and finishes at the same place of the Iliacus at the outer edge of the femur. (See picture B) Picture B. Iliopsoas. Note how the insertion of both muscles is on the outer edge of the femur head (EVEN IF IT APPEARS TO BE ON THE INNER SIDE, THE MUSCLES GO AROUND THE BONE!) Strengthening the Iliopsoas could tilt the pelvis into an exaggerated flexion which could cause the disks (rememer the cushions) to spill, while stretching it will take the pelvis into its "backbend paddling". One way of strengthening the Iliopsoas muscle is through "ab crunches". Paradoxically, excercising the abdominal muscles is meant to stabilize the lower back, however, according to Profesor David MacAmmond of Calgary, Canada , specialized in therapeutic yoga and kineseology, very little people who practice abdominal crunches have a healthy back due to the overstrengthening of the Iliopsoas. A good way of just excercising the abs without getting the Iliopsoas engaged is the following. 1. Lie on your back and bend your knees if needed. 2. put your hands beneath the head. 3. Try to lift your nose around 1 cm and feel your abdominals getting worked. 4. Repeat 5 times. 5. Now try to mimic that abdominal contraction without lifting your head. 6. Repeat 10 times. Through this excercise, nobody will ever develop a six pack, but that has never been the point of working the abdominal muscles. You want to protect your back, not to be a Greek sculpture with lower back pain! :) Another important muscle is the Latissiums dorsi (See picture C), which involves the movements of the arms with the spine. It also connects the sacrum with the back. Picture C. Latissimus dorsi The Latissimus dorsi is the largest muscle of the whole body. It starts at the sacrum, the spines of the thoracic, lumbar vertebrae, lower 3-4 ribs, and iliac crest, and inserts into the inner edge of the humerus (the upper bone of the arm) as shown in the picture. The fibers of the Latissimus dorsi are transverse. Transverse muscles are not meant for making small efforts for a long time, but rather for making a big short effort, therefore, the Latissimus dorsi must not engage in carrying the spine. The best way of not getting it involved is by widening it and giving space to the other deeper muscles (Erector spinae) to act. Dona Holleman proposes quite an innovative way to widen the Latissimus dorsi while sitting: she says that through the rooting (not pressing) of the outer wrist on the thighs, the Latissimus dorsi moves out of the way of the erectors of the spine. (This outer wrist point is known in Chinese medicine as the gate of heaven) The erector muscles of the spine are many and are the ones responsible for lifting the spine and keeping it up throughout your life (See picture D). Picture D. Erector spinae muscles. There is no particular way to activate this muscles since it is very hard to feel them. What I know through practice is that there needs to be widening of the Latissimus dorsi and rooting of the part which is in contact with the ground so the ground pushes your body up (3rd Law of Newton). Dona Holleman also states that one of the mantras of posture is to keep the sacrum away from the lumbar region. This is done through the rooting of the grounding part on the one hand, and the elongation of the other end on the other. One good way of excercising these muscles is to stand up straight keeping the sacrum away from the lumbar, feet at hips distance, shoulders above the hips and ears above the shoulders (Tadasana or mountain's pose), respecting all the natural curves of the spine and placing a 6-8 kg sandbag or book on top of the head. Try to lift the sandbag with your head keeping your ears away of the shoulders as much as possible while rooting the feet without pressing or blocking the knees. Feel the widening of the Latissimus dorsi and the elongation of the Erector spinae. This is the same action that takes place in most of the asanas, particularly on the standing ones. Once you have clear mastering of this concept you will be able to stand on your head which involves among a few other things, rooting the head on the floor, and elongating the feet upwards. Doing this will allow you to stay on your head for more than 10 minutes (otherwise you would be using the Latissimus dorsi!) [Do not go into head balance until you have a steady practice, and most certainly don't do it without supervision] Note how upright are these Gujarati women carrying water on their heads. Gujarati women carrying water on their heads. I hope I have given some clear and useful information. Keep tuned for more of other stuff :)

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