Use of pedometers to increase physical activity among children and adolescents with chronic kidney disease

Use of activity trackers to improve blood pressure in young people at risk for cardiovascular disease: a pilot randomized controlled trial

BACKGROUND

Promoting physical activity among young individuals with cardiovascular disease (CVD) risk factors such as hypertension, diabetes, or chronic kidney disease can lower systolic blood pressure (BP). We sought to determine whether a 6-month intervention using a physical activity tracker was feasible and effective, compared with usual care.

METHODS

Participants were recruited at a single academic medical center. Those aged 8-30 years were randomized in a 2:1 ratio to either the intervention (use of a Fitbit physical activity tracker coupled with feedback regarding the participant's step count) or usual care. The primary feasibility outcomes were screening-to-enrollment ratio and 6-month retention rates; the primary clinical outcome was a change in systolic BP from 0-6 months.

RESULTS

Sixty-three participants were enrolled (57% male; mean age: 18 ± 4 years). The screening-to-enrollment ratio was 1.8:1. Six-month retention was 62% in the intervention group and 86% in the control group (p = 0.08). Mean change in systolic BP in the intervention group was not significantly different from the control group at 6 months (- 2.3 mmHg; 95% CI - 6.5, 1.8 vs. 3.0 mmHg; 95% CI - 2.5, 8.4, respectively, p = 0.12).

CONCLUSIONS

Among children and young adults at elevated CVD risk, the use of a physical activity tracker coupled with tailored feedback regarding their step count progress was feasible but not sustained over time. Physical activity tracker use did not have a statistically significant effect on BP after 6 months. Augmented strategies to mitigate risk in young patients at high risk for early-onset CVD should be explored. This trial is registered at ClinicalTrials.gov (NCT03325426).

Effect of exercise training on functional capacity, muscle strength, exercise capacity, dialysis efficacy and quality of life in children and adolescents with chronic kidney disease: a systematic review and meta-analysis

PURPOSE

To synthesize the effect of exercise training on functional capacity, muscle strength, exercise capacity, dialysis efficacy, and quality of life (QOL) in children and adolescents with CKD.

METHODS

PubMed/Medline, Scopus, PEDro, Web of Science, CINAHL, Cochrane, and Embase were searched from inception to September 30, 2023. Randomized control trials (RCTs) and clinical trials that assessed the effect of exercise training programs on functional capacity, muscle strength, exercise capacity, dialysis efficacy, and QOL in children and adolescents with CKD were included. Random effect model and meta-regression were used for the meta-analysis.

RESULTS

Four clinical trials and three RCTs were included. The results showed that exercise training improves strength, but meta-analysis did not show a significant effect of exercise on functional capacity (WMD: 1.02; 95% CI: - 0.14 to 2.18; p = 0.083) and QOL (WMD: 8.00; 95% CI: - 3.90 to 19.91; p = 0.187). Subgroup analysis revealed that more than 25 sessions and 45 min per session of intervention, a PEDro score of more than 5, and being younger than 12 years of age had a large effect on functional capacity and QOL results. Due to the limited number of studies that reported the effect of exercise on dialysis efficacy and exercise capacity, the findings were inconclusive.

CONCLUSION

Exercise training could benefit children and adolescents with CKD by increasing their strength. Longer exercise interventions may be beneficial for improving functional capacity and QOL. Future well-designed RCTs should overcome the existing limitations using adequate sample sizes and longer exercise durations.

Patient education interventions for adolescent and young adult kidney transplant recipients- a scoping review

BACKGROUND

Adolescence and young adulthood are high risk periods for kidney transplant recipients. The reasons for this are complex; but are predominantly thought to be due to poor adherence to immunosuppressive medications. Patient education can help support young recipients to reduce their risk of behaviour-related transplant loss. The aim of this review was to understand what is known about education interventions targeted at adolescent and young adult kidney transplant recipients.

METHODS

Systematic scoping review methodology was utilised. Six online databases were searched for suitable articles. Articles were selected for full text review following title and abstract screening. Articles deemed eligible to be included in the review had data extracted, which were qualitatively analysed using thematic analysis. Findings were validated through a consultation exercise with both young recipients and healthcare professionals.

RESULTS

29 studies were eligible for inclusion in the review. There was a high level of heterogeneity in the content, mode, design, and measurement of efficacy of interventions in the selected studies. Traditional face-to-face education and transition clinics were the most common educational interventions. Using technology to enhance patient education was also a major theme identified. Few studies reported using educational theory or involving patients in intervention design.

DISCUSSION

Four key research gaps were identified. 1.) Lack of educational theory in intervention design 2.) Lack of patient/ stakeholder involvement 3.) Identifying best way to measure efficacy 4.) identifying novel future research questions within already well established paediatric and educational frameworks. Addressing these gaps in future research will help inform best-practice in this vulnerable population.

Cardiovascular disease risk factors and lifestyle modification strategies after pediatric kidney transplantation: what are we dealing with, and what can we target?

Kidney transplantation in pediatric patients can lead to partial improvement of some of the cardiometabolic parameters that increase the risk for cardiovascular disease (CVD) in patients with chronic kidney disease. However, even after restoration of kidney function, transplant recipients remain at risk for CVD due to the continual presence of traditional and non-traditional risk factors, including the side effects of immunosuppression and chronic inflammation. This educational review describes the prevalence of CVD risk factors in pediatric kidney transplant recipients and presents available evidence for therapeutic lifestyle changes and other non-pharmacologic strategies that can be used to improve traditional and modifiable CVD risk factors. Although trial-grade evidence for interventions that improve CVD in pediatric kidney transplant recipients is limited, potential strategies include lowering dietary sodium and saturated fat intake and increasing physical activity levels. Intensive follow-up may help patients achieve guideline-recommended goals for reducing their overall CVD risk.

Can 10 000 Healthy Steps a Day Slow Aortic Root Dilation in Pediatric Patients With Marfan Syndrome?

Background Stiffer aortas are associated with a faster rate of aortic root (AoR) dilation and higher risk of aortic dissection in patients with Marfan syndrome. We have previously shown that mild aerobic exercise reduces aortic stiffness and rate of AoR dilation in a Marfan mouse model. In this study, we investigated if these results could be translated to pediatric patients with Marfan syndrome. Methods and Results We enrolled 24 patients with Marfan syndrome aged 8 to 19 years to participate in a 6-month physical activity intervention, excluding those with ventricular dysfunction or prior history of aortic surgery. We instructed patients to take 10 000 steps per day, tracked by an activity tracker. At baseline and 6 months, we measured AoR dimension, arterial stiffness, endothelial function, physical activity indices, inflammatory biomarkers, and coping scores. Controls consisted of 15 age-matched patients with Marfan syndrome. Twenty-four patients with Marfan syndrome (median age, 14.4 years [interquartile range {IQR}, 12.2-16.8], 14 male patients) were enrolled. Baseline assessment demonstrated that the majority of these patients were sedentary and had abnormal arterial health. Twenty-two patients completed the intervention and took an average of 7709±2177 steps per day (median, 7627 [IQR, 6344-9671]). Patients wore their Garmin trackers at a median of 92.8% (IQR, 84%-97%) of their intervention days. AoR Z score in the intervention group had a significantly lower rate of change per year compared with the controls (rate of change, -0.24 versus +0.008; P=0.01). Conclusions In this clinical intervention in pediatric patients with Marfan syndrome, we demonstrated that a simple physical activity intervention was feasible in this population and has the potential to decrease the AoR dilation rate. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03567460.

Physical activity and the 'pediatric inactivity triad' in children living with chronic kidney disease: a narrative review

The ‘paediatric inactivity triad’ (PIT) framework consists of three complex inter-related conditions that influence physical inactivity and related health risks. In those living with chronic kidney disease (CKD), a multi-factorial milieu of components likely confound the PIT elements, resulting in a cycle of decreased physical functioning and reduced physical activity. In this review, we explore and summarize previous research on each of the three principal PIT components (exercise deficit disorder, dynapenia, and physical illiteracy) in the pediatric CKD population. We found those living with CKD are significantly physically inactive compared to their peers. Physical inactivity occurs early in the disease process and progressively gets worse as disease burden increases. Although physical activity appears to increase post-transplantation, it remains lower compared to healthy controls. There is limited evidence on interventions to increase physical activity behaviour in this population, and those that have attempted have had negligible effects. Studies reported profound reductions in muscle strength, physical performance, and cardiorespiratory fitness. A small number of exercise-based interventions have shown favourable improvements in physical function and cardiorespiratory fitness, although small sample sizes and methodological issues preclude the generalization of findings. Physical activity must be adapted and individualized to the needs and goals of the children, particularly those with acute and chronic medical needs as is the case in CKD, and further work is needed to define optimal interventions across the life course in this population if we aim to prevent physical activity declining further.

Patient-Reported Outcomes in Children With Chronic Kidney Disease

Patient-reported outcomes (PROs) are quantitative assessments of a patient's perspective on their health and are derived directly from the patient, as opposed to clinician interpretation. PROs can serve as unique tools to improve health care providers' understanding of the patient's daily lived experience and highlight salient domains that are specific to children with chronic kidney disease (CKD). As such, PROs fill an important gap in achieving optimal health and well-being for children with CKD. However, several knowledge gaps remain in the implementation of PROs within both the clinical and research realms. This review provides a broad overview of PRO development, implementation for children with CKD, and highlights future directions and challenges.

Physical Activity versus Sclerostin and Interleukin 6 Concentration in Patients Receiving Renal Replacement Therapy by Hemodialysis

Introduction

Chronic kidney disease and renal replacement therapy are associated with reduced motor activity, which may result in the presence of mineral bone disorders and an increase in inflammation markers. The aim of the study was to assess the relationship between the performance of daily physical activity, expressed in the number of steps performed by patients undergoing hemodialysis and the concentration of selected biochemical parameters (SCL, IL-6).

Patients and Methods

The study group (B) involved 33 patients aged 59.8 ± 9.8 years from the dialysis station at the Department of Nephrology, Transplantology and Internal Medicine PUM. In group B, interventions considering an increase in physical activity expressed in the number of steps were introduced. Group C consisted of 30 people aged 54.9 (9.37), with GFR over 60 mL/min/1.73m. Physical activity was measured with pedometers. Anthropometric and biochemical parameters were assessed at baseline, after the third and sixth month of the study. Descriptive statistics, intergroup comparisons using Mann–Whitney U test and Spearman correlation analysis were performed. The level of significance was set at p≤0.005.

Results

A relationship between IL-6 concentration and the number of steps in group B after three months of intervention was demonstrated. In group C, the concentration of SCL and IL-6 decreased with the increase in the number of steps taken. Only in group C the waist circumference decreased with the increase of the number of steps performed.

Conclusion

Patients receiving renal replacement therapy by hemodialysis showed significantly lower physical activity compared to people without kidney disease. Performing bigger number of steps can lower interleukin 6 levels in hemodialysis patients.

Group-Based Care in Adults and Adolescents With Hypertension and CKD: A Feasibility Study

Rationale & Objective

Group-based care provides an opportunity to increase patient access to providers without increasing physician time and is effective in the management of chronic diseases in the general population. This model of care has not been investigated in chronic kidney disease (CKD).

Study Design

Randomized controlled trial in adults (n = 50); observational study in adolescents (n = 10).

Setting & Participants

Adults and adolescents with CKD and hypertension in the Bronx, NY.

Intervention

Group-based care (monthly sessions over 6 months) versus usual care in adults. All adolescents received group-based care and were analyzed separately.

Outcomes

Participant attendance and satisfaction with group-based care were used to evaluate intervention feasibility. The primary clinical outcome was change in mean 24-hour ambulatory blood pressure. Secondary outcomes included physical activity, medication adherence, quality of life, and sodium intake as assessed by 24-hour urinary sodium excretion and food frequency questionnaires.

Results

Among adults randomly assigned to group-based care, attendance was high (77% of participants attended ≥3 sessions) and most reported higher satisfaction. Mean 24-hour ambulatory systolic blood pressure decreased by −4.2 (95% CI, −13.3 to 5.8) mm Hg in group-based care patients compared with usual care at 6 months but this was not statistically significant. Similarly, we did not detect significant differences in health-related behaviors (such as medication adherence, sodium intake, and physical activity) or quality-of-life measures between the 2 groups. Among the adolescents, attendance was very poor; self-reported satisfaction, although high, did not change from baseline compared with the 6-month follow-up.

Limitations

Small study size, missing data.

Conclusions

Group-based care is feasible and acceptable among adults with hypertension and CKD. However, a larger trial is needed to determine the effect on blood pressure and health-related behaviors. Patient participation may limit the effectiveness of group-based care models in adolescents.

Funding

National Institutes of Health R34 DK102174.

Trial registration

https://clinicaltrials.gov/show/NCT02467894.

Physical fitness and health-related quality of life in pediatric renal transplant recipients: An interventional trial with active video gaming

BACKGROUND

Pediatric renal transplant recipients are at increased risk for cardiovascular diseases, one contributing factor is reduced cardiorespiratory fitness. The purpose was to evaluate cardiorespiratory fitness, motor coordination, muscle strength, daily physical activity, and health-related quality of life and to find out, if active video gaming is effective for improving these items in this patient population.

METHODS

Twenty renal transplant recipients (13.5 ± 3.4 years) and 33 matched healthy controls (13.1 ± 3.2 years) performed a spiroergometry, a motor coordination test, and a maximal handgrip strength test. Quality of life was determined with a validated questionnaire, and daily physical activity was recorded with a physical activity monitor. Thirteen patients (12.9 ± 3.4 years) participated in a 6-week home-based exergaming intervention (3×/week for 30 minutes) and repeated all tests after that.

RESULTS

The renal transplant recipients exhibited a substantial impairment compared with the controls in peak oxygen consumption (-31%, P < .001), motor competence (-44%, P < .001), daily physical activity (-33%, P = .001), and quality of life (-12%, P = .017). Handgrip strength was similar in both groups. Despite of low compliance in the intervention group, steps per hour were significantly increased after 6 weeks of exergaming (+31%, P = .043); however, all other measures remained unchanged.

CONCLUSION

Cardiorespiratory fitness, motor competence, and quality of life are reduced in pediatric renal transplant recipients. Home-based exergaming is not appropriate to improve these items, probably due to a substantially impaired motor competence. However, it provided a stimulus for an increased daily physical activity.

Cardiovascular risk factors in children on dialysis: an update

Cardiovascular disease (CVD) is a life-limiting comorbidity in patients with chronic kidney disease (CKD). In childhood, imaging studies have demonstrated early phenotypic characteristics including increases in left ventricular mass, carotid artery intima-media thickness, and pulse wave velocity, which occur even in young children with early stages of CKD. Vascular calcifications are the signature of an advanced phenotype and are mainly found in adolescents and young adults treated with dialysis. Association studies have provided valuable information regarding the significance of a multitude of risk factors in promoting CVD in children with CKD by using intermediate endpoints of measurements of surrogate parameters of CVD. Dialysis aggravates pre-existing risk factors and accelerates the progression of CVD with additional dialysis-related risk factors. Coronary artery calcifications in children and young adults with CKD accumulate in a time-dependent manner on dialysis. Identification of risk factors has led to improved understanding of principal mechanisms of CKD-induced damage to the cardiovascular system. Treatment strategies include assessment and monitoring of individual risk factor load, optimization of treatment of modifiable risk factors, and intensified hemodialysis if early transplantation is not possible.

Sedentary Behaviors in Today's Youth: Approaches to the Prevention and Management of Childhood Obesity: A Scientific Statement From the American Heart Association

This scientific statement is about sedentary behavior and its relationship to obesity and other cardiometabolic outcomes in youth. A deleterious effect of sedentary behavior on cardiometabolic health is most notable for screen-based behaviors and adiposity; however, this relation is less apparent for other cardiometabolic outcomes or when sedentary time is measured with objective movement counters or position monitors. Increasing trends of screen time are concerning; the portability of screen-based devices and abundant access to unlimited programming and online content may be leading to new patterns of consumption that are exposing youth to multiple pathways harmful to cardiometabolic health. This American Heart Association scientific statement provides an updated perspective on sedentary behaviors specific to modern youth and their impact on cardiometabolic health and obesity. As we reflect on implications for practice, research, and policy, what emerges is the importance of understanding the context in which sedentary behaviors occur. There is also a need to capture the nature of sedentary behavior more accurately, both quantitatively and qualitatively, especially with respect to recreational screen-based devices. Further evidence is required to better inform public health interventions and to establish detailed quantitative guidelines on specific sedentary behaviors in youth. In the meantime, we suggest that televisions and other recreational screen-based devices be removed from bedrooms and absent during meal times. Daily device-free social interactions and outdoor play should be encouraged. In addition, parents/guardians should be supported to devise and enforce appropriate screen time regulations and to model healthy screen-based behaviors.

The under reporting of recruitment strategies in research with children with life-threatening illnesses: A systematic review

BACKGROUND

Researchers report difficulties in conducting research with children and young people with life-limiting conditions or life-threatening illnesses and their families. Recruitment is challenged by barriers including ethical, logistical and clinical considerations.

AIM

To explore how children and young people (aged 0-25 years) with life-limiting conditions or life-threatening illnesses and their families were identified, invited and consented to research published in the last 5 years.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, PsycINFO, Web of Science, Sciences Citation Index and SCOPUS were searched for original English language research published between 2009 and 2014, recruiting children and young people with life-limiting conditions or life-threatening illness and their families.

RESULTS

A total of 215 studies - 152 qualitative, 54 quantitative and 9 mixed methods - were included. Limited recruitment information but a range of strategies and difficulties were provided. The proportion of eligible participants from those screened could not be calculated in 80% of studies. Recruitment rates could not be calculated in 77%. A total of 31% of studies recruited less than 50% of eligible participants. Reasons given for non-invitation included missing clinical or contact data, or clinician judgements of participant unsuitability. Reasons for non-participation included lack of interest and participants' perceptions of potential burdens.

CONCLUSION

All stages of recruitment were under reported. Transparency in reporting of participant identification, invitation and consent is needed to enable researchers to understand research implications, bias risk and to whom results apply. Research is needed to explore why consenting participants decide to take part or not and their experiences of research recruitment.