Exercise In Chronic Kidney Disease Research Articles

Physical activity and exercise in chronic kidney disease: consensus statements from the Physical Exercise Working Group of the Italian Society of Nephrology

The Italian Society of Nephrology has tasked its Working Group on Physical Exercise with developing a consensus statement document on physical activity and exercise in patients with chronic kidney disease (CKD). This paper consists of 16 points that were discussed, and approved using the mini-Delphi method by 15 members of the working group. Each statement is based on a comprehensive review of the literature, clinical experience, and expert opinions. Overall, the statements affirm that regular physical activity and exercise training offer numerous benefits to CKD patients, including improved physical function, enhanced cardiometabolic and neuromuscular function, cognitive benefits, and an overall improvement in quality of life. Furthermore, exercise may provide nephroprotection and reduce mortality. These advantages are observed across all CKD stages, whether on conservative therapy or kidney replacement therapy (hemodialysis or peritoneal dialysis), and in kidney transplant recipients. Moreover, when physical activity and exercise training are implemented with appropriate precautions, they are safe in CKD patients. Gradual physical activity and customized exercise programs should be tailored to the patient's exercise tolerance, potentially enhancing compliance. Clinicians are encouraged to use a series of questionnaires and tests to assess the patient's level of physical activity and performance. However, exercise and physical activity are poorly implemented in clinical practice due to many barriers related to patients and healthcare staff. Overcoming these barriers requires the proactive role of the nephrologists, who should actively incorporate exercise training and promote physical activity within routine care plans. Adopting a multidisciplinary team approach, which includes nephrologists, nurses, exercise professionals, and dietitians, is crucial for providing comprehensive rehabilitation for CKD patients. Integrating new technologies and remote check ups could further enhance the effectiveness of these interventions.Graphical abstract

#1551 The presence of proteinuria is associated with impaired cerebral oxygenation during exercise in chronic kidney disease

Abstract Background and Aims Cognitive impairment and reduced exercise tolerance are common in patients with chronic kidney disease (CKD), in part due to reduced brain function. Cerebral perfusion and oxygenation are significant determinants of brain activation and have been shown to be significantly impaired in CKD. This analysis aims to examine the impact of proteinuria on cerebral oxygenation during a mild physical stress in patients with pre-dialysis CKD. Method 66 patients with CKD stage 2-4 were included in this post-hoc analysis; 24-h urine samples were used for evaluation of proteinuria. All participants underwent a 3-min intermittent handgrip exercise (HG) at 35% of their maximal voluntary contraction. Changes in cerebral oxygenation (oxyhemoglobin-O2Hb) and deoxyhemoglobin-HHb) and regional blood volume (total hemoglobin-tHb) were continuously recorded during HG-exercise by near-infrared spectroscopy (NIRS). Results No significant differences between the 2 groups were detected in age (proteinuric vs nonproteinuric: 68.4 ± 10.6 vs 67.2 ± 10.8; p = 0.676), eGFR (41.3 ± 18.9 vs 46.3 ± 14.8; p = 0.248) and BMI (28.4 ± 4.9 vs 28.1 ± 4.8; p = 0.803). The MMSE score (proteinuric vs nonproteinuric: 28.0 ± 1.6 vs 28.0 ± 1.7; p = 0.938) and MVC (22.3 ± 7.0 vs 23.9 ± 7.5; p = 0.416) were not significantly different between groups. The average response in cerebral oxygenation during exercise was lower in patients with proteinuric CKD (O2Hb: 1.02 ± 0.87 vs 1.61 ± 0.95; p = 0.018 and diffO2Hb 1.53 ± .97 vs 2.07 ± 1.25; p = 0.065). The average tHb response (index of regional-blood-volume) was also lower in patients with proteinuria (0.51 ± 1.08 vs 1.16 ± 0.92 p = 0.013); however, no differences in HHb (-0.50 ± 0.55 vs -0.45 ± 0.54; p = 0.717) –an index of oxygen extraction capacity- among groups were detected. In univariate linear analysis the level of proteinuria did not show significant correlations with NIRS parameters. Conclusion The presence and not the level of proteinuria is associated with impaired brain activation during a mild physical task in patients with predialysis CKD. Future studies evaluating the role of proteinuria in the decline of cerebral function and cognitive impairment are needed.

PAG Masked Protective Physical Exercise-Induced High H2S Levels in 5/6 Nephrectomized Rats

Background: To investigate the mechanisms of exercise therapeutics in preclinical animal models of chronic kidney disease (CKD), PAG (D, L-propargylglycine), an inhibitor of hydrogen sulfide production, was used to examine the protective effects of physical activity on oxidative stress and inflammation levels during CKD. Methods: Male Wistar rats with CKD, induced by the 5/6 nephrectomy procedure and subjected to 8 weeks of exercise training, received injections of PAG, a cystathionine γ-lyase (CSE) inhibitor, at a dose of 19 mg/kg, i.p., twice a week during those 8 weeks. The systolic blood pressure (BP) and renal sympathetic nerve activity (RSNA) were assessed. Additionally, plasma creatinine, BUN, renal hydrogen sulfide (H2S) levels, oxidative stress, and inflammatory markers were evaluated. Results: In the PAG group, inhibition of H2S production significantly reversed the improvements in plasma creatinine, BUN, renal malondialdehyde (MDA) level, superoxide dismutase (SOD) activity, TNF-α, and IL-6 that were achieved by exercise. Additionally, high RSNA and high BP, which were also reversed in the PAG group, compared to the CKD group subjected to exercise training. Conclusions: The results suggest that the improvement in BP, oxidative stress, and inflammation status by exercise in CKD may be at least partially due to CSE/H2S signaling.

Exercise in Chronic Kidney Disease Patients Does Not Significantly Alter Fibrosis in Quadriceps Muscle

Background: Chronic kidney disease (CKD) is commonly associated with decreased physical activity and muscle dysfunction. Muscles in CKD become fibrotic, containing excess extracellular matrix (ECM), particularly collagen. Collagen is cross-linked in the ECM, and increased cross-linking is often associated with fibrosis, stiffness, and reduced ECM remodeling. However, it is not known how exercise in patients with CKD may impact the extent of collagen cross-linking or fibrosis. Additionally, muscle fibrosis may impair muscle adaptations to exercise including, fiber size, fiber type, or vasculature. We predicted that collagen content and cross-linking would decrease, and there would be more Type I fibers and larger fiber size in the patients that were in the exercise group. Methods: Participants were randomized to exercise (n=15) or no exercise (n=5) groups in the Exercise Study Testing Enhanced Energetics of Mitochondria (ESTEEM) clinical trial of non-dialysis patients with CKD. The exercise program consisted of 35 min sessions, 3 times a week for 12 weeks consisting of high-intensity interval training, strength training, and power walking. Vastus lateralis biopsies were obtained before and after the 12 weeks of exercise. A bundle of muscle tissue was powdered and separated into a pepsin soluble and insoluble fraction before applying a hydroxyproline assay for collagen content, with the insoluble fraction representing more cross-linked collagen. For histological analysis 10 μm thick cryosections were stained with Picrosirius Red, or immunofluorescent stains to investigate satellite cells, vasculature, fibro-adipogenic progenitors (FAPs), and muscle fiber types. Picrosirius red sections were imaged under polarized light to look at birefringence as a measure of collagen density. Sections that were stained for fiber type and vasculature were analyzed using semi-automatic muscle analysis using segmentation of histology (SMASH). Results: The overall amount of collagen and collagen cross-linking were not altered in either the exercise or no exercise groups. Picrosirius red stained sections did not reveal a change in ECM area or collagen packing density with exercise. Surprisingly minimum ferret diameter and percentage of type I (slow twitch) fibers decreased in most patients that underwent the exercise program. Type I and type IIa (fast oxidative) fiber size also significantly decreased, while there was no change in type IIx (fast glycolytic) fiber size. Conclusion: This study shows that exercise does not dramatically reduce ECM content or muscle fibrosis in patients with CKD. Surprisingly, the response to exercise was opposite of that anticipated in healthy subject with exercise in CKD producing smaller muscle fibers and a shift away from more oxidative type I fibers. This shows that exercise may have limited capacity to enhance function in CKD muscle, potentially due to irreversible fibrosis. Work supported by mitochondrial bioenergetics in persons with chronic kidney disease (NIH R03DK114502). This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Beneficial effects of physical exercise on the osteo-renal Klotho-FGF-23 axis in Chronic Kidney Disease: A systematic review with meta-analysis.

The aim of this study was to investigate the efficacy of physical exercise in chronic kidney disease, describing its impact on the Klotho-FGF23 axis. PubMed, Web of Science and Scopus databases, updated to January 2023, were searched. The present study employed mean difference and a 95% confidence interval (CI) to examine the efficacy of the intervention. Heterogeneity was assessed through inconsistency statistics (I2). Out of the 299 studies identified, a total of 4 randomized controlled trials (RCTs), comprising 272 participants, met the eligibility criteria. Compared with the control group, physical exercise significantly decreased the concentrations of FGF23 (MD: -102.07 Pg/mL, 95% CI: -176.23.47, -27.91 I2= 97%, p = 0.001), and a significantly increased the concentrations of Klotho protein: (MD: 158.82 Pg/mL, 95% CI: 123.33, -194.31, I2 = 0%, p = 0.001). The results of our study indicated that the exercise has a direct relationship with Klotho-FGF23 axis. We can conclude that physical exercise in patients with CKD produces beneficial effects on the pathophysiological components related to this disease, including cardiorespiratory fitness and vascular functions. As observed, both endurance and aerobic physical exercise increase Klotho production and decrease FGF23 levels. Evidence indicates that exercise attenuates the progression of CKD, improves uremic parameters and down-regulates inflammation-related markers.

The Role of Physical Exercise in Chronic Kidney Disease

Chronic kidney disease (CKD) affects more than 10% of the general population worldwide, amounting to more than 800 million individuals. Some important conditions associated with CKD are hypertension, diabetes, dyslipidemia, sedentary lifestyle, and smoking. According to World Health Organization (WHO), regular physical activity helps to prevent and manage non-communicable diseases such as diabetes and hypertension, associated with weight reduction. It is known that a decrease in systolic blood pressure is associated with significant reduction in all causes of mortality and major cardiovascular events. As far as diabetes concerned, beyond first-line medication, healthy lifestyle behaviours should be considered, in which physical activity is included. Training leads to improved skeletal muscle response with increased expression and activity of proteins involved in glucose metabolism and insulin sensitivity. Concerning dyslipidemia, one of the recommended interventions encompasses lifestyle, noting that in patients with low, moderate, or high cardiovascular risk, depending on the LDL value, the treatment involves physical activity and weight loss or its association with pharmacotherapy. CKD patients have some particularities that condition the exercise prescription and the interpretation of its benefits. This review is intended to systematize the importance of exercise in CKD and its determinants.

Making the Case for Standardized Outcome Measures in Exercise and Physical Activity Research in Chronic Kidney Disease

Physical activity and exercise are core components of lifestyle modification strategies for the management of chronic kidney disease (CKD). Yet, physical activity levels have consistently remained poor across all stages of CKD. Exercise interventions, including aerobic and resistance training, and lifestyle interventions promoting physical activity, have been shown to improve a multitude of clinical endpoints and factors important to patients; however, despite the evidence, the provision of physical activity in clinical practice is still inadequate. The usefulness of any study hinges on the adequacy and clinical relevance of the outcomes and outcome measures used. Inconsistent reporting and wide disparities in outcome use across studies limit evidence synthesis to help guide clinical practice. The kidney exercise and physical activity field has been particularly prone to inconsistent outcome reporting. To ensure research is relevant and able to influence clinical practice and future research, we need to ensure the use (and reporting) of standardized, relevant outcome measures. Core outcome sets (COS) have been widely developed across many chronic conditions, yet these COS have not been tailored to physical activity and exercise in CKD. Outcomes in clinical research need to be relevant to the intervention being employed. From this perspective, we summarize the importance that standardizing outcomes and outcome measures may have in relation to physical activity and exercise interventions for people living with kidney disease.

Aerobic exercise training attenuates the peak blood pressure response to exercise in chronic kidney disease

Chronic kidney disease (CKD) is an expanding public health problem. Patients with CKD have reduced exercise tolerance and are at a high risk for cardiovascular disease and events. Previous work has demonstrated that an exaggerated blood pressure response to exercise occurs in these patients which may contribute to their poor exercise capacity and increased cardiovascular risk. The purpose of this study was to test the hypothesis that 12 weeks of aerobic exercise training would attenuate the peak blood pressure response to exercise in patients with CKD. METHODS: Twenty-eight patients with stage 3 and 4 CKD (mean±SD: estimated glomerular filtration rate 43 ± 12 ml/min/1.73 m2) were randomly allocated to an exercise training (EX) or control (CON) group. EX consisted of 12 weeks of supervised aerobic exercise 3 times per week. Exercise duration and intensity progressively increased to 45 minutes at 65% to 85% heart rate reserve. CON received routine care. Cardiopulmonary exercise testing was performed on a cycle ergometer at baseline and following 12 weeks. Exercise intensity increased by 15W every minute and automated breath-by-breath gas analysis averaged over 10 seconds intervals was acquired throughout the protocol. Blood pressure (Tango M2, SunTech, NC) was recorded at rest and every 2 min throughout exercise and recovery. RESULTS: Twelve weeks of EX increased both VO2peak (p<0.01) and exercise duration (p<0.01). At 12 weeks, peak systolic blood pressure was not different from baseline in the EX (207 ± 32 vs 206 ± 35 mmHg; p=0.86) or CON groups (192 ± 39 vs 194 ± 39 mmHg; p=0.85). Exercise training significantly reduced peak diastolic blood pressure (91 ± 14 vs 81 ± 14; p = 0.002) whereas this was unchanged in the CON group (82 ± 15 vs 84 ± 15 mmHg; p=0.66). CONCLUSION: Twelve weeks of aerobic exercise training improved exercise capacity and attenuated peak diastolic blood pressure during exercise in patients with stage 3 & 4 CKD. The reduced blood pressure reactivity observed following exercise training in CKD may reduce cardiovascular risk and requires further investigation. Funding source: National Institutes of Health, National Heart Lung and Blood Institute grant R01HL113514 This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Neurocirculatory regulation and adaptations to exercise in chronic kidney disease.

Chronic kidney disease (CKD) is characterized by pronounced exercise intolerance and exaggerated blood pressure reactivity during exercise. Classic mechanisms of exercise intolerance in CKD have been extensively described previously and include uremic myopathy, chronic inflammation, malnutrition, and anemia. We contend that these classic mechanisms only partially explain the exercise intolerance experienced in CKD and that alterations in cardiovascular and autonomic regulation also play a key contributing role. The purpose of this review is to examine the physiological factors that contribute to neurocirculatory dysregulation during exercise and discuss the adaptations that result from regular exercise training in CKD. Key neurocirculatory mechanisms contributing to exercise intolerance in CKD include augmentation of the exercise pressor reflex, aberrations in neurocirculatory control, and increased neurovascular transduction. In addition, we highlight how some contributing factors may be improved through exercise training, with a specific focus on the sympathetic nervous system. Important areas for future work include understanding how the exercise prescription may best be optimized in CKD and how the beneficial effects of exercise training may extend to the brain.

PS-BPB06-4: EXERCISE TRAINING AMELIORATES RENAL OXIDATIVE STRESS IN RATS WITH CHRONIC KIDNEY DISEASE

Background: The renoprotective effects of long-term exercise in chronic renal failure have been reported. However, the details of the mechanism remains unclear. This study investigated the renal protective effect of long-term exercise on renal oxidative stress in a rat model of chronic renal failure. Methods: Male Sprague-Dawley rats were divided into Sham, 5/6 nephrectomy + sedentary, and 5/6 nephrectomy + exercise training groups. 5/6 nephrectomy + exercise training group underwent treadmill running for 12weeks. Systolic blood pressure and urinary protein were measured every 2 weeks. Renal function, renal histology and oxidative stress-related factors were examined after completion of the exercise protocol. Results: 5/6 nephrectomized rats exhibited hypertension, proteinuria, renal dysfunction glomerulosclerosis, renal interstitial fibrosis, and exercise training ameliorated them. 5/6 nephrectomy increased urinary malondialdehyde, renal cortical NADPH oxidase and xanthine oxidase activities and exercise training inhibited the 5/6 nephrectomy-increased urinary malondialdehyde, renal cortical NADPH oxidase and xanthine oxidase activities. Plasma malondialdehyde was not affected by 5/6 nephrectomy or exercise. Conclusions: In rats with chronic kidney disease, long-term exercise prevented hypertension, renal dysfunction, glomerulosclerosis, and renal interstitial fibrosis. Mechanism for the antihypertensive and renal protective effects of long-term exercise in chronic kidney disease may involve the reduction of renal oxidative stress.

Skeletal Muscle Complications in Chronic Kidney Disease.

To provide an overview of the recent literature investigating the pathophysiology of skeletal muscle changes, interventions for skeletal muscle, and effects of exercise in chronic kidney disease (CKD). There are multiple CKD-related changes that negatively impact muscle size and function. However, the variability in the assessment of muscle size, in particular, hinders the ability to truly understand the impact it may have in CKD. Exercise interventions to improve muscle size and function demonstrate inconsistent responses that warrant further investigation to optimize exercise prescription. Despite progress in the field, there are many gaps in the knowledge of the pathophysiology of sarcopenia of CKD. Identifying these gaps will help in the design of interventions that can be tested to target muscle loss and its consequences such as impaired mobility, falls, and poor quality of life in patients with CKD.

Spectral Analysis of Resting Near‐Infrared Spectroscopy Shows Preserved Endothelial Function after Aerobic Training Exercise in Chronic Kidney Disease

This study aims to evaluate the effectiveness of aerobic exercise training on microcirculatory function among individuals with chronic kidney disease (CKD). Microcirculatory dysfunction is a prevalent complication in CKD that progresses as CKD evolves. Endothelial dysfunction is an early manifestation of microvascular disease and contributes to increased cardiovascular‐related mortality in CKD. Evidence indicates that endothelial dysfunction might be linked to deficits in blood perfusion and oxygen delivery. Aerobic exercise has been shown to improve cardiorespiratory function and blood pressure control for adults with CKD. Previous work has validated correspondence of specific frequency intervals in resting microvascular blood flow fluctuations with physiological events. Specifically, the spectrum amplitude from three frequency intervals (0.0095 – 0.02 Hz, 0.02 – 0.06 Hz, 0.06 – 0.15 Hz) have been attributed to microvascular regulation by endothelial, neurogenic, and myogenic origins, respectively. We hypothesized that 12 weeks of aerobic exercise would improve endothelial function in CKD.Ten CKD participants (Table 1) were randomized into treatment and control groups that performed progressive aerobic cycling exercise (N = 5) for 20‐45 min up to 80% of heart rate reserve and non‐aerobic, stretching exercise (N = 5). Each group performed activities 3 days/week for 12 weeks. Resting microvascular blood flow was measured in the forearm for 5 minutes using total hemoglobin (tHb) signal from near‐infrared spectroscopy. Reactive hyperemic index (RHI) was measured using peripheral artery tonometry at the upper arm, providing an accepted, single‐value index of endothelial function. Both measures were obtained at the beginning (baseline) and end of the 12‐week intervention (EOS), respectively. The resting tHb signal was analyzed using wavelet transform to obtain time‐frequency information on microcirculation regulated by endothelial, neurogenic, and myogenic functions. Differences at baseline and EOS were assessed using pairwise Student’s t‐test (statistical significance: p < 0.05). The Pearson correlation coefficient between RHI and individual mean spectral amplitude was also obtained.Endothelial spectral amplitudes significantly decreased (p = 0.007) in the stretching group over the 12‐week intervention, suggesting decreased endothelial function (Fig.1). There was no significant change in the endothelial spectral amplitude (p = 0.16) in the cycling group. Changes in individual endothelial spectral amplitude and RHI were moderately correlated (r = 0.57 and p = 0.02).In conclusion, spectral analysis of resting microvascular blood flow in CKD suggests preserved endothelial function over 12 weeks of progressive aerobic cycling exercise, compared with a decline in those who performed a non‐aerobic stretching exercise. Ongoing work focuses on adapting and applying this wavelet methodology to MRI‐derived signals that provide temporo‐spatially resolved information on tissue oxygenation and perfusion. Resting microcirculatory properties yielded from this work may be useful for monitoring disease progression and guiding targeted therapeutic strategies to improve microvascular function in CKD.

Aerobic exercise training improves endothelial function and attenuates blood pressure reactivity during maximal exercise in chronic kidney disease.

Patients with chronic kidney disease (CKD) have exaggerated increases in blood pressure during exercise that are associated with endothelial dysfunction. We hypothesized that aerobic exercise training would improve endothelial function and attenuate blood pressure reactivity during exercise in CKD. Sedentary individuals with CKD stages III-IV underwent 12 wk of aerobic cycling exercise (n = 26) or nonaerobic exercise (n = 22, control). Both interventions were performed 3 days/wk and matched for duration. Endothelial function was measured via peripheral arterial tonometry and quantified as reactive hyperemia index (RHI). Peak oxygen uptake (V̇o2peak) was assessed via maximal treadmill exercise testing with concomitant blood pressure monitoring. All measurements were performed at baseline and after the 12-wk intervention. A linear mixed model was used to compare the rate of increase in blood pressure during the test. RHI improved with exercise (Pre = 1.78 ± 0.10 vs. Post = 2.01 ± 0.13, P = 0.03) with no change following stretching (Pre = 1.73 ± 0.08 vs. Post = 1.67 ± 0.10, P = 0.69). Peak systolic blood pressure during the maximal treadmill exercise test was lower after exercise training (Pre = 186 ± 5 mmHg, Post = 174 ± 4 mmHg, P = 0.003) with no change after stretching (Pre = 190 ± 6 mmHg, Post = 190 ± 4 mmHg, P = 0.12). The rate of increase in systolic blood pressure during the V̇o2peak test tended to decrease after training for both groups (-2 mmHg/stage) with no differences between groups (P = 0.97). There was no change in V̇o2peak after either intervention. In conclusion, aerobic exercise training improves endothelial function and attenuates peak blood pressure reactivity during exercise in CKD.NEW & NOTEWORTHY Patients with chronic kidney disease (CKD) exhibit increased blood pressure reactivity during exercise that is associated with endothelial dysfunction. Twelve weeks of structured, aerobic, exercise training improves endothelial function and attenuates peak blood pressure responses during exercise in CKD stages III-IV.

Inflammation and physical dysfunction: responses to moderate intensity exercise in chronic kidney disease.

People with chronic kidney disease (CKD) experience skeletal muscle wasting, reduced levels of physical function and performance, and chronic systemic inflammation. While it is known that a relationship exists between inflammation and muscle wasting, the association between inflammation and physical function or performance in CKD has not been well studied. Exercise has anti-inflammatory effects, but little is known regarding the effect of moderate intensity exercise. This study aimed to (i) compare systemic and intramuscular inflammation between CKD stage G3b-5 and non-CKD controls; (ii) establish whether a relationship exists between physical performance, exercise capacity and inflammation in CKD; (iii) determine changes in systemic and intramuscular inflammation following 12 weeks of exercise; and (iv) investigate whether improving inflammatory status via training contributes to improvements in physical performance and muscle mass. This is a secondary analysis of previously collected data. CKD patients stages G3b-5 (n=84, n=43 males) and non-CKD controls (n=26, n=17 males) underwent tests of physical performance, exercise capacity, muscle strength and muscle size. In addition, a subgroup of CKD participants underwent 12 weeks of exercise training, randomized to aerobic (AE, n=21) or combined (CE, n=20) training. Plasma and intramuscular inflammation and myostatin were measured at rest and following exercise. Tumour necrosis factor-α was negatively associated with lower $^{^{^{.}}}{\rm V}$O2Peak (P=0.01), Rectus femoris-cross sectional area (P=0.002) and incremental shuttle walk test performance (P<0.001). Interleukin-6 was negatively associated with sit-to-stand 60 performances (P=0.006) and hand grip strength (P=0.001). Unaccustomed exercise created an intramuscular inflammatory response that was attenuated following 12 weeks of training. Exercise training did not reduce systemic inflammation, but AE training did significantly reduce mature myostatin levels (P=0.02). Changes in inflammation were not associated with changes in physical performance. Systemic inflammation may contribute to reduced physical function in CKD. Twelve weeks of exercise training was unable to reduce the level of chronic systemic inflammation in these patients, but did reduce plasma myostatin concentrations. Further research is required to further investigate this.

Intradialytic physical exercise in chronic kidney disease: a systematic review of health outcomes

Introduction: Chronic kidney disease (CKD) is a general term for heterogeneous disorders that affect the structure and function of the kidney. Complications of CKD significantly limit exercise (Ex) tolerance by reducing functional capacity, endurance, and strength. However, the practice of regular Ex contributes to delaying the progression of CKD and stimulating improvements in health-related quality of life (HRQOL). Ex performed during the period of hemodialysis may be the best option when stimulating adherence and being under medical supervision. The purpose of the paper is to examine the effectiveness of intradialytic (iHD) Ex on health outcomes in patients with CKD by identifying the most appropriate component of Ex. Material and method: Systematic review, based on PRISMA guidelines, performing a structured search in Medline, SciELO and Cochrane Library Plus databases. Publications from the last 5 years relating iHD Ex and CKD up to 31 December 2019 were included. The methodological quality of the articles was evaluated using the McMaster critical review form. Results: We found 7 articles that described increases in endurance, upper and lower limb muscle strength, and HRQL of CKD patients providing emotional, social and psychological improvements. In addition, iHD Ex is able to control oxidative stress, inflammation, improve the lipid profile and stimulate endothelial progenitor cells, which together reduce the risk of mortality associated with multiple comorbidities in CKD patients, especially cardiovascular ones. Conclusions:Ex provides improvements in physical function and capacity, HRQL and biological markers. Aerobic Ex, muscle strength Ex and combined Ex programs are used.

An International Delphi Survey on Exercise Priorities in CKD

IntroductionDefining the role of exercise in chronic kidney disease (CKD) is a top research priority for people with CKD. We aimed to achieve consensus on specific research priorities in exercise and CKD among an international panel of stakeholders.MethodsUsing the Delphi method, patients/caregivers, researchers, clinicians, and policymakers submitted their top research priorities in round 1 and ranked their importance in rounds 2 and 3 using a 9-point Likert scale. The mean, median, and proportion of scores ranked 7 to 9 were calculated. Consensus was defined as priorities that scored above the overall mean and median score within each stakeholder panel. Qualitative description was used to understand participants’ rankings.ResultsSeventy participants (78% response) completed round 1: 15 (21.4%) clinicians, 33 (47.1%) researchers, 13 (18.6%) policymakers, and 9 (12.9%) patients; (85.7%) completed round 3. The top research priorities were defining exercise-related outcomes meaningful to patients, identifying patients’ motivation and perspective towards exercise, understanding the effect of exercise on the risk of institutionalization, mortality, and mobility, and understanding the effect of pre- and post-transplant exercise on postoperative recovery. Themes from the qualitative analysis were individualization, personal experience, and holistic approach to exercise (patients), the need to address common clinical problems (clinicians), developing targeted interventions (researchers), and the importance of evidence-based development versus implementation (policymakers).ConclusionsPreventing physical disability was a common priority. Policymakers emphasized that more efficacy studies were needed. Other panels expressed the need for holistic and targeted exercise interventions and for outcomes that address common clinical problems.

A randomized trial of aerobic exercise in chronic kidney disease: Evidence for blunted cardiopulmonary adaptations.

Patients with chronic kidney disease have reduced cardiorespiratory fitness levels that contribute to mortality. The purpose of this study was to investigate the effects of aerobic exercise on cardiopulmonary function in patients with chronic kidney disease. A total of 36 patients (mean [SD] estimated glomerular filtration rate 44 [12] ml/min/1.73m2) were randomly allocated to an exercise training or a control arm over 12 weeks. The exercise training group performed aerobic exercise for 45min 3 times/week at 65% to 80% heart rate reserve. The control group received routine care. Outcome measures were assessed at baseline and 12 weeks. Cardiopulmonary exercise testing was performed on a cycle ergometer with workload increased by 15W/min. A battery of physical function tests were administered. Habitual physical activity levels were recorded via accelerometry. Data are mean [SD]. Exercise training improved VO2peak as compared with the control group (exercise: 17.89 [4.18] vs 19.98 [5.49]; control: 18.29 [6.49] vs 17.36 [5.99] ml/kg/min; P<0.01). Relative O2 pulse improved following exercise, suggestive of improved left ventricular function (exercise: 0.12 [0.02] vs 0.14 [0.04]; control: 0.14 [0.05] vs 0.14 [0.04] ml/beat/kg; P=0.03). Ventilation perfusion mismatching (VE/VCO2) remained evident after exercise (exercise: 32 [5] vs 33 [5]; control: 32 [7] vs 34 [5] AU; P=0.1). Exercise did not affect the ventilatory cost of oxygen uptake (VE/VO2; exercise: 40 [7] vs 42 [8]; control: 3 [7] vs 41 [8] AU; P=0.5) and had no effect on autonomic function assessed by maximal and recovery heart rates. We found no changes in physical function or habitual physical activity levels. Cardiopulmonary adaptations appeared to be attenuated in patients with chronic kidney disease and were not fully restored to levels observed in healthy individuals. Improvements in exercise capacity did not confer benefits to physical function. Interventions coupled with exercise may be required to enhance adaptations in chronic kidney disease. Performed according to CONSORT guidelines; ClinicalTrials.gov: NCT02050035.

What is the role of exercise in chronic kidney disease?

What is the role of exercise in chronic kidney disease?

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

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. Studies continue to demonstrate wide-ranging benefits of exercise across CKD; however, implementation of exercise remains scarce. Future research needs include evaluating the efficacy of larger and/or more comprehensive interventions on clinically important outcomes. It is hoped with increasing global evidence, high-quality clinical studies, and sustained clinician and patient engagement, exercise programs will become better prioritized in the nephrology field.

Is the peripheral muscle weakness a limitation to exercise on chronic kidney disease?

Abstract Introduction: Chronic kidney disease (CKD) is a global public health problem with systemic repercussions, compromising muscle function and making patients less exercise tolerant. Objective: To verify the contribution of peripheral muscle strength in the exercise capacity of patients in hemodialysis (HD), as well as to compare peripheral muscle strength and exercise capacity between renal patients and healthy individuals. Method: 50 patients with chronic kidney disease (CKD) who performed HD and 13 healthy subjects underwent anthropometric evaluation, evaluation of peripheral muscle strength, pulmonary function test and exercise capacity assessment. Results: Simple linear regression indicated that the peripheral muscle strength contributed 41.4% to the distance walked in the six-minute walk test (R2 0.414; p &lt; 0.001), showing that for every 1 Kgf reduced in the right lower limb the patient it stops walking 0.5m while for every 1 Kgf reduced in the lower left limb the patient stops walking 0.8m. In addition, it was observed that patients with CKD had a reduction in right lower limb muscle strength (129.44 ± 48.05 vs. 169.36 ± 44.30, p = 0.002), left (136.12 ± 52, 08 vs 168.40 ± 43.35, p = 0.01) and exercise capacity (421.20 ± 98.07 vs. 611.28 ± 80.91, p &lt; 0.001) when compared to healthy pairs. Conclusion: Peripheral muscle weakness is an important limiting factor for exercise in CKD and patients on HD experience a decline in peripheral muscle strength and exercise capacity when compared to healthy individuals.