Becoming mindful of mindfulness: a promising approach to reducing sympathetic nervous system overactivity in chronic kidney disease

Chronic kidney disease (CKD) is a global health issue associated with increased cardiovascular disease risk and mortality. One proposed mechanism for this heightened risk is chronic overactivation of the sympathetic nervous system, contributing to adverse cardiovascular outcomes. This underscores the need for affordable, lifestyle-based approaches that can be utilized across diverse clinical settings and patient populations to mitigate sympathetic nervous system overactivity in individuals with CKD. Mindfulness meditation aims to promote effective self-emotion regulation through non-judgemental present-moment awareness and a shift in stress appraisal, ultimately reducing the stress-reactivity response. A single mindfulness meditation session acutely increases heart rate variability and reduces muscle sympathetic nerve activity (MSNA) burst frequency in individuals with CKD (Park et al., 2014). A recent systematic review with meta-analysis demonstrated that mindfulness-based stress reduction (MBSR) has beneficial effects on systolic blood pressure, reducing self-reported stress and anxiety for individuals with cardiovascular disease (Marino et al., 2021). No previous studies have tested the sustained effects of MBSR on MSNA in individuals with CKD. A recent study by Jeong et al. (2024), published in the Journal of Physiology, addressed this gap with a well-designed randomized controlled trial to investigate whether an 8-week MBSR intervention reduces resting muscle sympathetic nerve activity and sympathetic reactivity to stress in patients with stages III-IV CKD (Jeong et al., 2024). Participants were randomly stratified by CKD stage into either the MBSR group or a Health-Enhancement Program (HEP) active control. The 8-week MBSR intervention consisted of weekly 2.5-h supervised sessions focusing on psychoeducation, mindfulness practice and ∼45 min of assigned mindfulness practice, emphasizing a daily mindfulness routine. The HEP group matched the time course and support of the MBSR group but participated in music therapy, nutritional education, posture and balance work, walking and stretching, along with ∼45 min of daily video recorded practice. At baseline and 8-weeks, resting continuous beat-beat blood pressure and MSNA (direct peroneal nerve recording via microneurography) were recorded in the supine position. All three measures were also continuously recorded during stress protocols (mental arithmetic, static handgrip exercise and cold pressor test). Resting MSNA, blood pressure and heart rate were not different in both groups between baseline and post-intervention. The MBSR group had a reduction in the ΔMSNA burst frequency and ΔMSNA incidence over 3 min of mental arithmetic between baseline and post-intervention, whereas no change was observed within the HEP group. ΔMSNA burst incidence was reduced over 3 min of static handgrip exercise after MBSR, but this was not different within the HEP group. Blood pressure and heart rate reactivity during mental arithmetic, static handgrip exercise and the cold pressor test were not different from baseline to post-intervention in MBSR and HEP groups. Overall, this study provides evidence for the use of mindfulness practice in reducing MSNA reactivity during acute psychological and physical stressors in CKD patients. MBSR may reduce the risk of cardiovascular disease in CKD patients by attenuating sympathetic nervous system activity. Jeong et al. (2024) propose that mindfulness training promotes psychological adaptations that may have downstream effects, attenuating physiological reactivity. These reductions in reactivity may be specific to certain stressors with no significant reduction in MSNA observed in response to the cold pressor test, but responses were attenuated to mental arithmetic and handgrip exercise (Figure 1). Sympathetic nervous system activity during stressors may be influenced by pathways involving both peripheral and central mechanisms. Peripheral mechanisms may include the exercise pressor reflex involving metaboreceptors and mechanoreceptors in skeletal muscles, or the arterial baroreflex. These mechanisms may also involve central components such as higher brain centres implicated with sympathetic outflow. This aligns with aspects promoted during the mindfulness intervention including psychological and exercise-related stimuli through components including psychoeducation, walking meditation and yoga. The reduction in MSNA during stressors driven by central and peripheral components, but not those predominantly involving nociception (as no effect was observed with the cold pressor test), is an important area of future physiological inquiry to determine which aspects of central versus peripheral sympathetic regulation are modifiable in response to MBSR interventions. Interestingly, despite the reduction in MSNA in response to arithmetic and handgrip stressors, no changes were observed in blood pressure. This suggests that alterations in the transduction of a sympathetic burst into a blood pressure response, which are mediated by α-adrenergic receptor mechanisms (Fairfax et al., 2013), are a worthy direction of future work. Altogether, the physiological insight gleaned from the present study advances our understanding of lifestyle interventions on sympathetic nervous system regulation. The study will prompt important physiological work aiming to understand the intricacies of which aspects of autonomic function are responsible for the muted reactivity responses to stressors. MBSR has gained attention in clinical settings due to its positive influence on coping with psychological risk factors and improving physiological outcomes (Marino et al., 2021). Stress management skills are integral for decreasing cardiovascular disease risk and mortality in individuals with CKD. This has become increasingly relevant in recent years due to the escalating prevalence of mental health challenges and the need for accessible solutions (Magomedova & Fatima, 2025). MBSR is a low-risk intervention that is suitable for many populations making it a valuable stress management skill. MBSR can be safely practised in combination with strategies for improving cardiovascular health including nutritional education, sleep management, physical activity and exercise. The model presented by Jeong et al. (2024) represents an important step in advancing the development of MBSR and supports its clinical utility as a viable component of treatment strategies for individuals with CKD. Unlike many treatment strategies that face barriers to practicality such as time constraints among healthcare professionals and resource limitations, mindfulness can be easily implemented with minimal effort and shared quickly through simple materials like pamphlets or remote options when intensive in-person intervention is not possible. For example, although many studies were unable to continue their research during the COVID-19 pandemic, the authors successfully conducted their intervention virtually with low drop-out from the MBSR intervention (2/14, 14% attrition), high-class adherence (mean: 95% ± 10%) and strong participant satisfaction, highlighting the adaptability of their MBSR intervention. Moreover, the authors also incorporated homework in the form of video guides and mandatory practice that also demonstrated strong adherence (mean: 78% ± 23%). This seems to indicate that, at least in CKD patients, such an approach is both feasible and well accepted and could help address some of the common challenges encountered by clinicians. The thorough investigation by Jeong et al. (2024) makes a valuable contribution to the field regarding how mindfulness-based interventions influence sympathetic nervous system activity in individuals with CKD. The study employed a rigorous experimental protocol, incorporating direct measures of MSNA during resting, and both mental and physical stress tasks. The findings underscore the potential of mindfulness training to attenuate mental and physical stress-induced sympathetic responses, which may hold implications for stress management in CKD populations. Importantly, these results emphasize the potential utility of MBSR as an accessible clinical tool to possibly help manage and mitigate cardiovascular risk in patients with CKD. This work lays an important foundation for future research seeking to further explore the role of mindfulness meditation in altering sympathetic nervous system regulation. Such insights could inform the development of targeted therapies aimed at improving the long-term cardiovascular health and overall well-being of individuals living with CKD. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article. None declared. All authors contributed equally to conceptualizing, drafting and revising of the manuscript and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All persons designated as authors qualify for authorship, and all those who qualify for authorship are listed. All authors have read and approved the final version. None. The authors acknowledge Dr Myles O'Brien for his input and discussion of the article content.