Mortality and morbidity following exercise-based renal rehabilitation in patients with chronic kidney disease: the effect of programme completion and change in exercise capacity.

Sharlene A Greenwood,Iain C Macdougall,Emmanuel Mangahis,Juliet Mayes,Iain Waite,Denise Grant,Ellen Castle,Kamer Shevket,Helen L Maclaughlin,Olivia Crabb,Herolin Lindup

doi:10.1093/ndt/gfy351

Sharlene A Greenwood, Iain C Macdougall + Show 9 more

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https://doi.org/10.1093/ndt/gfy351

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Abstract

BackgroundTwelve weeks of renal rehabilitation (RR) have been shown to improve exercise capacity in patients with chronic kidney disease (CKD); however, survival following RR has not been examined.MethodsThis study included a retrospective longitudinal analysis of clinical service outcomes. Programme completion and improvement in exercise capacity, characterised as change in incremental shuttle walk test (ISWT), were analysed with Kaplan–Meier survival analyses to predict risk of a combined event including death, cerebrovascular accident, myocardial infarction and hospitalisation for heart failure in a cohort of patients with CKD. Time to combined event was examined with Kaplan–Meier plots and log rank test between ‘completers’ (attended >50% planned sessions) and ‘non-completers’. In completers, time to combined event was examined between ‘improvers’ (≥50 m increase ISWT) and ‘non-improvers’ (<50 m increase). Differences in time to combined event were investigated with Cox proportional hazards models (adjusted for baseline kidney function, body mass index, diabetes, age, gender, ethnicity, baseline ISWT and smoking status).ResultsIn all, 757 patients (male 54%) (242 haemodialysis patients, 221 kidney transplant recipients, 43 peritoneal dialysis patients, 251 non-dialysis CKD patients) were referred for RR between 2005 and 2017. There were 193 events (136 deaths) during the follow-up period (median 34 months). A total of 43% of referrals were classified as ‘completers’, and time to event was significantly greater when compared with ‘non-completers’ (P = 0.009). Responding to RR was associated with improved event-free survival time (P = 0.02) with Kaplan–Meier analyses and log rank test. On multivariate analysis, completing RR contributed significantly to the minimal explanatory model relating clinical variables to the combined event (overall χ2 = 38.0, P < 0.001). ‘Non-completers’ of RR had a 1.6-fold [hazard ratio = 1.6; 95% confidence interval (CI) 1.00–2.58] greater risk of a combined event (P = 0.048). Change in ISWT of >50 m contributed significantly to the minimal explanatory model relating clinical variables to mortality and morbidity (overall χ2 = 54.0, P < 0.001). ‘Improvers’ had a 40% (hazard ratio = 0.6; 95% CI 0.36–0.98) independent lower risk of a combined event (P = 0.041).ConclusionsThere is an association between completion of an RR programme, and also RR success, and a lower risk of a combined event in this observational study. RR interventions to improve exercise capacity in patients with CKD may reduce risk of morbidity and mortality, and a pragmatic randomised controlled intervention trial is warranted.

Highlights

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in patients with chronic kidney disease (CKD)
Morbidity and mortality status were ascertained for 757 patients from across the CKD trajectory (242 haemodialysis patients, 221 kidney transplant recipients, 43 peritoneal dialysis patients, 251 non-dialysis CKD patients) who were referred for renal rehabilitation (RR) over a 12-year period from 2005 to 2017 and fulfilled the inclusion/exclusion criteria
This study examined the effect of completing an exercise-based RR programme, and the success in the programme, on the time to the combined outcome of all-cause mortality and CV morbidity in a population of patients with all stages of CKD

Summary

Introduction

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in patients with chronic kidney disease (CKD). Exercise-based rehabilitation, which promotes a more physically active lifestyle, has the potential to positively impact upon functional ability, aerobic capacity and the quality of life of patients with CKD, independent of the stage of the disease process [3,4,5]. Twelve weeks of renal rehabilitation (RR) have been shown to improve exercise capacity in patients with chronic kidney disease (CKD); survival following RR has not been examined. Programme completion and improvement in exercise capacity, characterised as change in incremental shuttle walk test (ISWT), were analysed with Kaplan–Meier survival analyses to predict risk of a combined event including death, cerebrovascular accident, myocardial infarction and hospitalisation for heart failure in a cohort of patients with CKD. Time to combined event was examined with Kaplan–Meier plots and log rank test between ‘completers’ (attended >50% planned sessions) and ‘non-completers’. Sensory (vibration threshold, monofilament insensitivity to light and standard touch), motor [compound motor action potentials (CMAPs), nerve conduction velocities (NCVs)] and autonomic (heart rate response and recovery after a 400-m walk test) nerve function as well as participant characteristics were compared across cystatin C- and creatinine-based estimated glomerular filtration rate categorized as 60 (CKD) or >60 mL/min/1.73 m2 (non-CKD)

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