The impact of exercise on physical function, cardiovascular outcomes and quality of life in chronic kidney disease patients: a systematic review

A systematic review and meta-analysis investigating the impact of exercise interventions on heart rate variability in hemodialysis patients

Patients with chronic kidney disease have a high incidence of cardiovascular diseases, and autonomic dysfunction has a determinant role in the relevant declines. Physical exercise influences heart rate variability and cardiac autonomic modulation. Thus, our objective was to systematically review, with a meta-analysis, the correlation between physical exercise interventions and alterations in cardiac autonomic modulation in hemodialysis patients. A customized research strategy was used across four databases. The search yielded 392 studies, with eight randomized clinical trials included (396 participants), indicating that the investigated indices favor the intervention group by increasing autonomic activity. The exercise training probably increases the standard deviation of all NN intervals (20.71 ms CI 95% [9.55, 31.87], p < 0.001, I²=95%) compared to the control group and showing an moderate certainty, was the most commonly used index (seven studies). Mean RR (35.57 ms CI 95% [14.56, 56.57], p = 0.91, I²=0%), the root mean square sum of squares of differences between NN intervals (10.55 ms CI 95% [6.75, 14.34], p = 0.37, I²=4%), and LF/HF (0.28 ms (n.u) [0.11, 0.44], p = 0.18, I²=39%) were also in favor of the training group. However, based on the GRADE analysis we are uncertain whether Mean RR can increase after an exercise intervention, as well RMSSD and LF/HF may increase slightly, we obtained low certainty of this evidence. The exact magnitude of the impact of physical training on the alteration of cardiac autonomic modulation in this patient population has yet to be conclusively defined.

Exercise and Cognitive Function in Chronic Kidney Disease: A Systematic Review and Meta-Analysis of Efficacy and Harms

Key Points

Cognitive impairment is common in CKD. Exercise targets multiple risk factors of cognitive decline. Meta-analysis found that exercise had a small but positive effect on cognitive function in CKD, albeit the quality of evidence was low. Further analyses revealed that aerobic exercise was particularly beneficial and that exercise did not substantially increase harms.

Background

People living with CKD are at higher risk of cognitive impairment. Exercise may improve cognitive function. This systematic review and meta-analysis of randomized controlled trials was completed to determine the efficacy and harms of exercise in improving cognitive function in people living with CKD.

Methods

A systematic literature review identified randomized controlled trials of people with any stage of CKD, with an intervention that exercised large-muscle groups, and with a validated outcome measure of cognitive function. First, harms were analyzed. Then a random-effects meta-analysis was completed with subsequent planned subgroup analyses to investigate heterogeneity between CKD stages and treatments; between different exercise types, durations, and intensities; and between different outcome methodologies. Finally, quality of evidence was rated.

Results

Nineteen trials randomized 1160 participants. Harms were reported on 94 occasions in intervention groups versus 83 in control. The primary analysis found that exercise had a small but statistically significant effect on cognition in CKD (effect size=0.22; 95% confidence intervals, 0.00 to 0.44; P = 0.05). However, the quality of evidence was rated as low. Subgroup analyses found that type of exercise moderated the effect on cognition (chi square=7.62; P = 0.02), with positive effects only observed following aerobic exercise (effect size=0.57; 95% confidence interval, 0.21 to 0.93; P = 0.002).

Conclusions

Across the spectrum of CKD, exercise had a small but positive and clinically meaningful effect on cognitive function and did not seem to be harmful. Aerobic exercise was particularly beneficial. However, the results must be interpreted cautiously because of the low quality of evidence. Nevertheless, care teams may choose to recommend aerobic exercise interventions to prevent cognitive decline. Researchers should design unbiased studies to clarify what intensity and duration of exercise is required to maximize efficiency of such exercise interventions.

An Exercise and Wellness Behavior Change Program for Solid Organ Transplant: A Clinical Research Protocol for the Transplant Wellness Program

Background

Exercise prehabilitation is an evidence-based, safe, and effective method to increase quality of life, physical fitness and function, and post-surgical outcomes in solid organ transplant (SOT) patients. However, few prehabilitation programs for SOT patients exist in practice. Furthermore, there is a lack of multimodal prehabilitation programs that include behavior change support. To address this need, the Transplant Wellness Program (TWP) was designed.

Objectives

The objective of the TWP is to assess both the effectiveness and implementation of a comprehensive and multimodal exercise and wellness behavior change intervention for patients undergoing kidney or liver transplant.

Design

The TWP is a hybrid effectiveness-implementation trial consisting of exercise and wellness behavior change support.

Patients

Individuals who are in evaluation or listed for kidney or liver transplant in Southern Alberta, Canada.

Measurements

The primary outcomes of self-reported exercise and quality of life are assessed at intake, post-exercise intervention, 6 months post-intake, 12 weeks post-transplant, and annually for 5 years after program completion. Functional fitness measures will be assessed at intake, post-exercise intervention, 12 weeks post-transplant, 6 months post-intake, and 1-year post-intake. The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework is used to determine the impact of TWP at the individual and health care system level.

Methods

Recruitment began in November 2023 and will continue until November 2028. Participants take part in a 12-week exercise intervention and are offered individualized and group behavior change support. Continued exercise support is offered through maintenance classes after the completion of the 12-week intervention.

Limitations

The design of the hybrid effectiveness-implementation trial with a single experimental group will not allow for comparisons to a control or usual care group, potentially impacting internal validity. Differences in number of participants between organ groups (kidney vs liver) and cohorts (pre-transplant vs post-transplant) will likely be uneven, requiring consideration when running and interpreting analyses.

Conclusions

The TWP aims to support patients throughout the transplant journey through a multimodal and comprehensive exercise and wellness behavior change program. Results from this study will determine the effectiveness of the program and inform future scale-up and sustainability.

Trial registry number

NCT06367244.

Effects of intradialytic bicycle ergometer exercise on transcription factors NF-ĸB and Nrf2 in patients with chronic kidney disease: A randomized crossover clinical trial

PURPOSE

To evaluate the effects of an intradialytic aerobic exercise training program on the expression of transcription factors nuclear factor κappa B (NF-κB) and nuclear factor erythroid 2-related factor 2 (Nrf2), related to inflammatory and antioxidant pathways, respectively, in patients with chronic kidney disease (CKD) on hemodialysis.

METHODS

This was a longitudinal, randomized clinical trial with a washout period and crossover performed with 33 patients randomized into two groups: Exercise (individualized intradialytic aerobic exercise on an adapted stationary exercise bike) three times per week for three months and control (without exercise). After the washout period (1 month), the exercise group became the control, and the other group performed the exercises for another three months. Blood sample collection, food intake, and anthropometry were evaluated at the beginning and end of each study phase. Nrf2, its target gene NAD(P)H quinone oxidoreductase 1 (NQO1), and NF-κB transcription factors were evaluated by quantitative real-time polymerase chain reaction (qRT-PCR) and the inflammatory cytokines tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) by ELISA assay.

RESULTS

Eighteen patients [11 men, 44.1 ± 8.4 years, 17.3 (6.6-124) months on HD] completed all the study. The obtained data revealed that the intervention did not affect Nrf2, NQO1, and NF-κB mRNA expression. Also, TNF-α levels were not changed. However, IL-6 showed a tendency to decrease after the exercise intervention (p = 0.054).

CONCLUSION

In hemodialysis patients, three months of intradialytic aerobic exercise did not modulate the transcription factors associated with inflammation (NF-κB) and antioxidant activity (Nrf2 and NQO1).

CLINICAL TRIALS REGISTRATION NUMBER

NCT04375553.

Association of Tai Chi and Square Dance with Cognitive Function in Chinese Older Adults

OBJECTIVE

This study explores the association of Tai Chi and square dance with cognitive function and compares the effects of the two fitness programs on cognitive function in Chinese older adults.

METHODS

A total of 1732 older people (aged 60 years and over) met the inclusion criteria from the 2018 Chinese Longitudinal Healthy Longevity Survey. Based on the frequency of participating in Tai Chi and square dance, older adults were divided into three groups: a Tai Chi group (n = 234), a square dance group (n = 345), and a control group (n = 1153). Cognitive function was measured using a modified Mini-Mental State Examination (MMSE). Participation in Tai Chi or square dance was investigated by asking the subjects to report how often they participated in the fitness programs.

RESULTS

Older adults in both the Tai Chi group and the square dance group had higher scores in all MMSE items, including orientation, registration, attention and calculation, recall, and language, compared to those in the control group. But there were no significant differences in any MMSE items between the Tai Chi group and the square dance group. Multiple regression analysis showed that participating in Tai Chi or square dance, age, educational level, and sex can predict cognitive function in older people.

CONCLUSION

Our findings suggest that participating in Tai Chi and square dance are associated with better cognitive function, and Tai Chi and square dance have similar effects on cognitive function in the Chinese older population.

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.

Narrative Review: Clinical Implications and Assessment of Frailty in Patients With Advanced CKD

Frailty is a multidimensional clinical syndrome characterized by low physical activity, reduced strength, accumulation of multiorgan deficits, decreased physiological reserve, and vulnerability to stressors. Frailty has key social, psychological, and cognitive implications. Frailty is accelerated by uremia, leading to a high prevalence of frailty in patients with advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD) as well as contributing to adverse outcomes in this patient population. Frailty assessment is not routine in patients with CKD; however, a number of validated clinical assessment tools can assist in prognostication. Frailty assessment in nephrology populations supports shared decision-making and advanced communication and should inform key medical transitions. Frailty screening and interventions in CKD or ESKD are a developing research priority with a rapidly expanding literature base.

Exercise for patients with chronic kidney disease: from cells to systems to function

Chronic kidney disease (CKD) is among the leading causes of death and disability, affecting an estimated 800 million adults globally. The underlying pathophysiology of CKD is complex creating challenges to its management. Primary risk factors for the development and progression of CKD include diabetes mellitus, hypertension, age, obesity, diet, inflammation, and physical inactivity. The high prevalence of diabetes and hypertension in patients with CKD increases the risk for secondary consequences such as cardiovascular disease and peripheral neuropathy. Moreover, the increased prevalence of obesity and chronic levels of systemic inflammation in CKD have downstream effects on critical cellular functions regulating homeostasis. The combination of these factors results in the deterioration of health and functional capacity in those living with CKD. Exercise offers protective benefits for the maintenance of health and function with age, even in the presence of CKD. Despite accumulating data supporting the implementation of exercise for the promotion of health and function in patients with CKD, a thorough description of the responses and adaptations to exercise at the cellular, system, and whole body levels is currently lacking. Therefore, the purpose of this review is to provide an up-to-date comprehensive review of the effects of exercise training on vascular endothelial progenitor cells at the cellular level; cardiovascular, musculoskeletal, and neural factors at the system level; and physical function, frailty, and fatigability at the whole body level in patients with CKD.

The effects of exercise training interventions on depression in hemodialysis patients

Purpose

Depression considerably influences the clinical outcomes, treatment compliance, quality of life, and mortality of hemodialysis patients. Exercise plays a beneficial role in depressive patients, but its quantitative effects remain elusive. This study aimed to summarize the effects of exercise training on depression in patients with end-stage renal disease undergoing hemodialysis.

Methods

The PUBMED, EMBASE, and Cochrane Library databases were systematically searched from inception to April 2023 to identify published articles reporting the effect of exercise training on the depression level of patients with End-Stage Renal Disease undergoing hemodialysis. Data were extracted from the included studies using predefined data fields by two independent researchers. The Cochrane Handbook for Systematic Reviews of Interventions and Joanna Briggs Institute Critical Appraisal Checklist for Quasi-Experimental Studies were employed for quality evaluation.

Results

A total of 22 studies enrolling 1,059 patients who participated in exercise interventions were included. Hemodialysis patients exhibited superior outcomes with intradialytic exercise (SMD = -0.80, 95% CI: -1.10 to -0.49) and lower levels of depression following aerobic exercise (SMD = -0.93, 95%CI: -1.32 to -0.55) compared to combined exercise (c - 0.85, 95% CI: -1.29 to -0.41) and resistance exercise (SMD = -0.40, 95%CI: -0.96 to 0.17). Regarding exercise duration, patients manifested lower depression levels when engaging in exercise activities for a duration exceeding 6 months (SMD = -0.92, 95% CI: -1.67 to -0.17). Concerning the duration of a single exercise session, the most significant improvement was noted when the exercise duration exceeded 60 min (SMD = -1.47, 95% CI: -1.87 to -1.06).

Conclusion

Our study determined that exercise can alleviate depression symptoms in hemodialysis patients. This study established the varying impacts of different exercise parameters on the reduction of depression levels in hemodialysis patients and is anticipated to lay a theoretical reference for clinicians and nurses to devise tailored exercise strategies for interventions in patients with depression.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database, with registration number CRD42023434181.

[Recommendations for the rehabilitation of patients with chronic kidney disease requiring hemodialysis (literature review)]

Chronic kidney disease (CKD) is a global health problem, CKD is widespread in the world, on average it is detected in 10-13% of the adult population. Sedentary patients with CKD on dialysis have a higher risk of mortality. Despite the significant association of physical function with mortality in patients with CKD, physical function is not routinely assessed and exercise is not a component of the routine management of patients with CKD on dialysis.

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of the influence of motor rehabilitation methods on the prognosis of patients with chronic kidney disease (CKD) using hemodialysis (HD) from the standpoint of evidence-based medicine according to a scientometric analysis of the literature.

MATERIAL AND METHODS

An analysis was carried out of systematic reviews (search depth 70 years) and network meta-analyses to assess the effectiveness of physical exercise, its intensity and duration, performed interdialytic and intradialytic in the rehabilitation of patients with CKD with renal failure requiring hemodialysis. We reviewed articles in foreign journals on the PubMed, Embase, CINAHL, Web of Science, Wan Fang data, Cochrane CENTRAL and Scopus platforms.

RESULTS

The use of different types of physical exercise with varying intensities and durations both during and outside of dialysis in CKD patients requiring hemodialysis has shown that aerobic exercise, resistance exercise and a combination of both are most effective in improving their physical condition and quality life. Meta-analyses provide evidence to support the value of intradialytic exercise compared with interdialytic exercise for dialysis patients. It is also noted that moderate-intensity exercise can be performed in various forms, both during and outside of dialysis, and the data studied demonstrate that moderate-intensity exercise best improves physical function.

CONCLUSION

Future large RCTs should pay more attention to rehabilitation and exercise programs for CKD patients requiring HD. To encourage inactive patients with CKD to engage in physical exercise, educating them about the effects of exercise is imperative. Accumulating evidence suggests that rehabilitation of patients with visceral disorders, such as renal, cardiac, and pulmonary disorders, can not only improve physical performance and quality of life, but also improve survival. Modern comprehensive rehabilitation of patients with CKD is aimed at prolonging life, which represents a new concept in renal rehabilitation.

Comparative efficacy of nine exercise methods on the prognosis in chronic kidney disease patients with hemodialysis: a systematic review and network meta-analysis

BACKGROUND

Several kinds of physical activities have been applied to improve the prognosis of patients with hemodialysis (HD). However, the comparative efficacy of physical activities on the outcomes in HD patients is still unknown. This study explored the effectiveness and safety of all exercise types in HD patients.

METHODS

We searched randomized clinical trials from the PubMed, EMBASE, and Cochrane Library databases. Physical exercises interventions included resistance exercise (RE), aerobic exercise (AE), electrical muscle stimulation (EMS), range of motion (ROM), resistance exercise + aerobic exercise (RE + AE), stretching exercise (STE), respiratory muscle training (RMT), peripheral muscle training (PMT), walking exercise (WE), or usual care/sham exercise (UC/SE). Primary outcomes were six-minute walk test (6-mwt) and quality of life (QOL). Secondary outcomes were Kt/V, VO2max, hemoglobin (Hb), C-reactive protein (CRP), interleukin-6 (IL-6), and systolic and diastolic blood pressure (sbp and dbp). Frequentist network meta-analysis with multivariate random effects models provided mean with 95% confidence intervals (95%CI).

RESULTS

A total of 58 eligible studies were included. AE, RMT, and RE + AE significantly improved 6-mwt compared with UC/SE. SE was the worst intervention and reduced QOL much more than the UC/SE and other exercise types. AE and RE + AE were associated with higher VO2max, while ROM and RE + AE induced higher Hb levels. All physical activities did not elevate blood pressure, CRP and IL-6. Only ROM decreased sbp/dbp. CRP is significantly lower in RE.

CONCLUSION

Physical activities play a crucial role in the different outcomes of HD patients. They can be applied to specific area for their specific efficacy.

The Moderating Role of Health Variables on the Association between Physical Exercise and Quality of Life in Patients with End-Stage Renal Disease

Scientific evidence demonstrates the positive impact that physical exercise has on the quality of life (QOL) of patients with chronic kidney disease (CKD). However, no study has proposed a model investigating the effect physical exercise has on the QOL of end-stage renal disease (ESRD) patients, considering the most frequent associated diseases (diabetes/hypertension). The objectives were (1) to explore the relationship between physical exercise and the QOL of adults with ESRD, and (2) to examine the moderating and/or mediating role of relevant patient variables. This non-interventional study utilized an ex post facto retrospective data analysis design with a sample of 310 patients with ESRD through two validated questionnaires. The dependent variables were the QOL scale (KDQOL-SF), and the physical function dimension (EFFISICA). The independent variables were the regular practice of intense physical activity (DEPINTE) and the daily time (in hours) the patient is in a sedentary attitude (TiParado). The moderating variables were the clinical situation and associated diseases. The mediator variable used was the body mass index. Bivariate and multiple regression analyses were conducted. Findings suggest implementing intense physical activity in transplant recipients and programmes to avoid sedentary lifestyles in dialysis patients have a positive effect in the QOL of ESRD patients.

An international Delphi consensus statement on metabolic dysfunction-associated fatty liver disease and risk of chronic kidney disease

BACKGROUND

With the rising global prevalence of fatty liver disease related to metabolic dysfunction, the association of this common liver condition with chronic kidney disease (CKD) has become increasingly evident. In 2020, the more inclusive term metabolic dysfunction-associated fatty liver disease (MAFLD) was proposed to replace the term non-alcoholic fatty liver disease (NAFLD). The observed association between MAFLD and CKD and our understanding that CKD can be a consequence of underlying metabolic dysfunction support the notion that individuals with MAFLD are at higher risk of having and developing CKD compared with those without MAFLD. However, to date, there is no appropriate guidance on CKD in individuals with MAFLD. Furthermore, there has been little attention paid to the link between MAFLD and CKD in the Nephrology community.

METHODS AND RESULTS

Using a Delphi-based approach, a multidisciplinary panel of 50 international experts from 26 countries reached a consensus on some of the open research questions regarding the link between MAFLD and CKD.

CONCLUSIONS

This Delphi-based consensus statement provided guidance on the epidemiology, mechanisms, management and treatment of MAFLD and CKD, as well as the relationship between the severity of MAFLD and risk of CKD, which establish a framework for the early prevention and management of these two common and interconnected diseases.

Proteomic profiling of protein expression changes after 3 months-exercise in ESRD patients on hemodialysis

The prevalence of chronic kidney disease (CKD) is steadily increasing, and it is a global health burden. Exercise has been suggested to improve physical activity and the quality of life in patients with CKD, eventually reducing mortality. This study investigated the change in physical performance after exercise in dialysis-dependent patients with CKD and analyzed differentially expressed proteins before and after the exercise. Plasma samples were collected at enrollment and after 3 months of exercise. Liquid chromatography with tandem mass spectrometry analysis and data-independent acquisition results were analyzed to determine the significantly regulated proteins. A total of 37 patients on dialysis were recruited, and 16 were randomized to exercise for 3 months. The hand grip strength and the walking speed significantly improved in the exercise group. Proteome analysis revealed 60 significantly expressed proteins after 3 months of exercise. In the protein functional analysis, the significantly expressed proteins were involved in the immune response. Also, some of the key significantly expressed proteins [(M Matrix metallopeptidase 9 (MMP-9), Activin A Receptor Type 1B (ACVR1B), Fetuin B (FETUB)] were validated via an enzyme-linked immunosorbent assay. Our results showed that exercise in dialysis-dependent patients with CKD could improve their physical performance. These results indicated that this beneficial effect of exercise in these populations could be associated with immune response.

Effects of an 18-month community-based, multifaceted, exercise program on patient-reported outcomes in older adults at risk of fracture: secondary analysis of a randomised controlled trial

This study identified that an 18-month community-based, multifaceted, exercise program consisting of resistance, weight-bearing impact, and balance/mobility training combined with osteoporosis education and behavioural support can improve health-related quality of life (HRQoL) and osteoporosis knowledge in older adults at risk of fracture, but only for those adherent to the exercise regime.

PURPOSE

To evaluate the effects of an 18-month community-based exercise, osteoporosis education and behaviour change program (Osteo-cise: Strong Bones for Life) on HRQoL, osteoporosis knowledge and osteoporosis health beliefs.

METHODS

This was a secondary analysis of an 18-month randomised controlled trial in which 162 older adults aged ≥ 60 years with osteopenia or increased falls/fracture risk were randomized to the Osteo-cise program (n = 81) or control group (n = 81). The program consisted of progressive resistance, weight-bearing impact and balance training (3 days/week); osteoporosis education to facilitate self-management of musculoskeletal health and behavioural support to enhance adherence to exercise. HRQoL, osteoporosis knowledge and osteoporosis health beliefs were assessed using the EuroQoL questionnaire (EQ-5D-3L), Osteoporosis Knowledge Assessment Tool and Osteoporosis Health Belief Scale, respectively.

RESULTS

Overall, 148 participants (91%) completed the trial. Mean exercise adherence was 55% and mean attendance for the three osteoporosis educational sessions ranged from 63-82%. After 12 and 18 months, there were no significant effects of the Osteo-cise program on HRQoL, osteoporosis knowledge or health beliefs relative to controls. Per protocol analyses (≥ 66% exercise adherence; n = 41) revealed a significant net benefit in EQ-5D-3L utility for the Osteo-cise group relative to controls after 12 months (P = 0.024) and 18 months (P = 0.029) and a significant net improvement in osteoporosis knowledge scores at 18 months (P = 0.014).

CONCLUSION

This study supports the importance of adherence to exercise regimes, as adherence to the Osteo-cise: Strong Bones for Life program was associated with improvements in HRQoL and osteoporosis knowledge in older adults at increased risk for falls and fractures.

TRIAL REGISTRATION NUMBER

ACTRN12609000100291.

Comparison of effectiveness of Nintendo Wii-based exergaming and home-based fun video exercises in pediatric patients with chronic kidney disease

Functional capacity and quality of life (QoL) are reduced in children and adults with chronic kidney disease (CKD). Aerobic, strengthening exercises, and exergames are reported as effective in the treatment of symptoms associated with CKD. Unlike adult patients, there are insufficient studies investigating the effects of exercise on disease-related symptoms in pediatric CKD. This study aimed to compare the effects of Nintendo Wii-based exergaming and home-based fun video exercises on functional capacity, muscle strength, physical activity (PA), depression, fatigue, and QoL in pediatric patients with CKD. Twenty-three pediatric patients with CKD were included in the study and randomized to group I (Nintendo Wii Fit) and group II (home-based fun video exercises). Patients in both groups underwent exercise programs twice per week for 6 weeks. Functional capacity, muscle strength, PA, QoL, fatigue, and depression of the patients were evaluated before and after the treatments. Sixteen patients completed the study. After treatment, significant differences were observed in both groups on 6MWT, muscle strength, average daily steps, PedsQoL Child Self-Report PHSS, and the Visual Fatigue Scale. Left knee flexor muscle strength and average step counts were found to be superior in group I. Both exergaming and home-based fun video exercises provide positive effects on functional capacity, muscle strength, fatigue, PA, depression, and QoL in pediatric patients with CKD. We think that these exercise methods can help to protect physical and mental health of patients and should be included in treatment from the early stages of the disease.

The diagnostic efficacy of diffusion tensor imaging generated by gadolinium-based magnetic resonance imaging for patients with chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) can lead to systemic inflammatory responses and other cardiovascular disease. Diffusion tensor imaging findings generated by gadolinium-based MRI (DTI-GBMRI) is regarded as a standard method for assessing the pathology of CKD. To evaluate the diagnostic value of DTI-GBMRI for renal histopathology and renal efficiency, renal fibrosis and damage, noninvasive quantification of renal blood flow (RBF) were investigated in patients with CKD.

METHODS

CKD patients (n = 186) were recruited and underwent diagnosis of renal diffusion tensor imaging findings generated by MRI (DTI-MRI) or DTI-GBMRI to identify the pathological characteristics and depict renal efficiency. The cortical RBFs and estimated glomerular filtration rate were compared in CKD patients undergone DTI-GBMRI (n = 92) or DTI-MRI (n = 94).

RESULTS

Gadolinium enhanced the diagnosis generated by DTI-MRI in renal fibrosis, renal damage, and estimated glomerular filtration rate. The superiority in sensitivity and accuracy of the DTI-GBMRI method in assessing renal function and evaluating renal impairment was observed in CKD patients compared with DTI-MRI. Outcomes demonstrated that DTI-GBMRI had higher accuracy, sensitivity, and specificity than DTI-MRI in diagnosing patients with CKD.

CONCLUSION

In conclusion, DTI-GBMRI is a potential noninvasive method for measuring renal function, which can provide valuable information for clinical CKD diagnosis.

Aerobic Exercise Attenuates Kidney Injury, Improves Physical Performance, and Increases Antioxidant Defenses in Lungs of Adenine-Induced Chronic Kidney Disease Mice

The association between chronic kidney disease (CKD) and pulmonary pathophysiological changes is well stablished. Nevertheless, the effects of aerobic exercise (AE) on lungs of CKD need further clarification. Thus, Swiss mice were divided in control, AE, CKD, and CKD + AE groups. CKD was induced by 0.2% adenine intake during 8 weeks (4 weeks of CKD induction and 4 weeks of AE). AE consisted in running on treadmill, at moderate intensity, 30 min/day, 5 days/week, during 4 weeks. Twenty-four hours after the last training day, functional capacity test was performed, and 48 h after the test, mice were euthanized. CKD mice showed a significant increase in urine output, serum urea, and creatinine concentrations, and decreased body weight and urine density, besides oxidative damage (p = 0.044), edema area (p < 0.001), leukocyte infiltration (p = 0.040), and collagen area in lung tissue (p = 0.004). AE resulted in an increase of distance traveled (p = 0.049) and maximum speed (p = 0.046), increased activity of catalase (p = 0.031) and glutathione peroxidase (p = 0.048) in lungs, increased levels of nitric oxide (NOx) in serum (p = 0.001) and bronchoalveolar lavage fluid (p = 0.047), and decreased kidney histological injury (p = 0.018) of CKD mice. However, AE also increased oxidative damage (p = 0.003) and did not change collagen content or perivascular edema in lungs (p > 0.05) of CKD mice. Therefore, AE attenuated kidney injury and improved antioxidants defenses in lungs. Despite no significant changes in pulmonary damage, AE significantly improved physical performance in CKD mice.

Physical exercise and peritoneal dialysis: An area yet to be explored

Health-related quality of life (HRQoL) of patients suffering from chronic kidney disease (CKD) is profoundly impaired by their frailty, disability and decreased physical capacity. Especially among older patients, a high prevalence of low physical activity levels and reduced functional performance has been reported. Physical exercise training has been shown to have a beneficial impact, counteracting these same hazardous consequences of inactivity and sedentarism both on CKD and end-stage kidney disease (ESKD) patients on hemodialysis (HD) treatment. The evidence-based knowledge on the effects of physical exercise on ESKD patients undergoing Peritoneal Dialysis (PD) treatment is scarce, even though this is a continually growing population that shares the same risk factors and desired clinical outcomes as the previously mentioned groups of patients. Further investigation will be necessary to clarify whether this exercise-based approach may be suitable for the PD population. This paper's purpose is to review the available literature, including randomized controlled trials, reviews and meta-analysis results that assessed the impact of physical exercise on patients under PD treatment bearing in mind their HRQoL, physical functioning and cardiovascular parameters. Furthermore, it aims to evaluate the perceived significant barriers and limitations of the PD population in what concerns physical exercise practice and how nephrologists should address them.

Physical Exercise Affects Quality of Life and Cardiac Autonomic Modulation in Patients With Chronic Kidney Failure Submitted to Hemodialysis: A Randomized Clinical Trial

Performing physical exercise during hemodialysis has been debated regarding safety and efficacy for improving life quality for patients with chronic kidney disease (CKD). Thus, we explored the influence of physical exercise during hemodialysis on both autonomic modulation of heart rate and quality of life for patients with CKF in a randomized clinical trial. We randomly allocated participants requiring hemodialysis to an experimental exercise group (EG) and a control no-exercise group (CG) and assessed their quality of life with the Kidney Disease Quality of Life Short Form—KDQOL-SF™ 1.3 and with Polar RS800CX to monitor their heart rate variability (HRV) before and three months after the end of the exercise intervention. EG participants reported a significant increase in their quality of life ( p = .05, physical function, physical aspects, pain, emotional well-being, emotional function; p = .03, energy and fatigue) and showed HRV improvement ( p = .05, RMSSD, SDNN, and SD2; p = .004, SD1) after three months of exercise. Thus, we recommend supervised physical exercise during hemodialysis for carefully selected patients.

Frailty in chronic kidney disease: challenges in nephrology practice. A review of the current literature

Frailty is a multidimensional clinical syndrome characterised by low physical activity, reduced strength, accumulation of multi-organ deficits, decreased physiological reserve and vulnerability to stressors. Frailty pathogenesis and "inflammaging" is augmented by uraemia, leading to a high prevalence of frailty potentially contributing to adverse outcomes in patients with advanced chronic kidney (CKD) disease including end stage kidney disease (ESKD). The presence of frailty is a stronger predictor of CKD outcomes than estimated Glomerular Filtration Rate (eGFR) and more aligned with dialysis outcomes than age. Frailty assessment should form part of routine assessment of patients with CKD and inform key medical transitions. Frailty screening and interventions in CKD/ESKD should be a research priority. This article is protected by copyright. All rights reserved.

Effect of exercise on cognitive impairment in patients undergoing haemodialyses: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

The influence of exercise on cognition in patients undergoing haemodialysis has been examined. However, evidence elucidating the effects in this patient group is scarce.

OBJECTIVE

To examine the effect of exercise on cognitive impairment in patients undergoing haemodialysis and provide insight into the effects of various characteristics of exercise on cognitive impairment in this population.

DESIGN

A systematic review and meta-analysis, following the guidance of PRISMA was undertaken.

PARTICIPANTS

Adult patients undergoing haemodialysis.

RESULTS

This review found that exercise significantly improved cognitive impairment in patients undergoing haemodialysis (SMD = 0.37, 95% CI: 0.13, 0.60, p = 0.002). Subgroup analyses demonstrated that both intradialytic exercise (SMD = 0.82, 95% CI: 0.37, 1.26, p < 0.001) and interdialytic exercise (SMD = 0.24, 95% CI: 0.01, 0.47, p = 0.038), exercise for 16 weeks or over (SMD = 0.33, 95% CI: 0.07, 0.58, p = 0.012), and lasting for more than 30 minutes (SMD = 0.52, 95% CI: 0.17, 0.86, p = 0.004) significantly alleviated cognitive impairment. The effect of exercise on cognitive impairment in patients less than 65 years of age (SMD = 0.39, 95% CI: 0.10, 0.68, p = 0.009) was significantly better than those over 65.

CONCLUSION

Exercise significantly improves cognitive impairment in patients undergoing haemodialysis. Both Intradialytic and interdialytic exercise of at least 30 minutes duration, 3 times weekly, and at least for 16 weeks may play a significant role in alleviating cognitive impairment in patients under 65 years of age.

Effect of Online Home-Based Training on Functional Capacity and Strength in Two CKD Patients: A Case Study

Chronic kidney disease (CKD) is a clinical condition characterized by the loss of kidney function over time, as well as several complications affecting gastrointestinal, cardiovascular, and musculoskeletal systems. Physical exercise seems to induce positive adaptations in CKD patients, without side effects. Usually, these patients show a reduced physical activity and physical performance. The aim of this case-report was to evaluate the effects of an online training protocol on functional capacity and on muscle mass, in CKD stage III patients. Methods: Two CKD (stage III according to KDIGO guidelines) participants (1 female, Patient A; 1 male, Patient B) were enrolled and they performed an online tailored-supervised combined training lasting 12 weeks, including multi-joint strength exercises using TheraBand and an aerobic session at 65–70% of the patients' heart rate reserve. Results: Both patients showed an improving trend on functional capacity (6 minutes walking test: Patient A = +3%; Patient B = +5.3%) and on strength of the upper arms (handgrip strength test-right: Patient A = +13.4%; Patient B = +19.1%; handgrip strength test-left: Patient A = +42.8%; Patient B= +12.9%), as well as a reduction in inflammation and oxidative stress biomarkers. The protocol was feasible, and no side effects were evidenced. These case studies suggest that the online combined training can produce beneficial effects in CKD patients under conservative therapy, by reducing the CKD-related complications and improving the adherence to exercise of this population of patients, overcoming logistic barriers such as transportation, availability of facilities, and working and personal-life schedule.

Severity of protein-energy wasting and obesity are independently related with poor quality of life in peritoneal dialysis patients

Protein-energy wasting (PEW) and poor health-related quality of life (HRQoL) are independently associated with morbi-mortality in continuous ambulatory peritoneal dialysis (CAPD). PEW may reduce HRQoL; however, we hypothesized HRQoL is affected differentially by PEW degrees or by individual criteria of nutritional status. AIM: To evaluate HRQoL according to PEW severity and nutritional status indicators in CAPD. This is a cross-sectional study in 151 patients. Subjective global assessment (SGA) was employed, and nutritional status classified as normal, mild-moderate PEW, and severe PEW. HRQoL was evaluated using Kidney Disease Quality of Life Short Form™, including physical (PCS), mental (MCS) and kidney disease (KDCS) components, and their subscales. Dietary intake, anthropometric and biochemical variables were measured. Forty-six percent of patients were well-nourished, 44% had mild-moderate PEW, and 10% severe PEW. Compared with well-nourished patients, those with mild-moderate (p=0.06) and severe (p=0.005) PEW had lower HRQoL score [68 (52-75), 55 (45-72), 46 (43-58), respectively]. PCS, MCS, and KDCS and their subscales had lower values as PEW was more severe. Patients with obesity and hypoalbuminemia had significantly lower HRQoL overall and component scores than their counterparts. Dietary intake was not associated with quality of life. In multivariate analysis obesity, PEW (by SGA), hypoalbuminemia, and low educational level predicted poor HRQoL (χ² 58.2, p<0.0001). As conclusion, PEW severity was related with worse HRQoL, either as overall score or in every component or subscale in CAPD patients. Poor HRQoL was predicted independently by PEW severity and obesity; additional predictors were hypoalbuminemia and low education.

Results From a Physical Activity Intervention Feasibility Study With Kidney Inpatients

Background:

Individuals with end-stage kidney disease requiring dialysis are often physically inactive, resulting in reduced physical functioning, increased frailty, and reduced quality of life. Furthermore, extended hospital stays and frequent readmissions are common, exacerbating health care costs. Physical activity may improve physical functioning, disability, and frailty but is not part of standard care of patients requiring dialysis. Research is required to determine the feasibility of implementing physical function assessments and physical activity programs in kidney inpatients requiring dialysis.

Objective:

To assess the feasibility and preliminary efficacy of an early-physical activity intervention (Move More study) in the care of kidney inpatients requiring dialysis. It was hypothesized that the intervention would be feasible with regards to administration and participation, meeting a priori feasibility criteria, and that kidney inpatients would benefit from participating.

Design:

Pilot study.

Setting:

Patient Unit 37, Foothills Medical Center, Calgary, AB, Canada.

Patients:

Kidney in-patients receiving dialysis.

Measurements:

Feasibility data were collected for recruitment, participation, assessment completion, physical activity completion, and adverse events. Participant and healthcare practitioner (HCP) satisfaction with the intervention was assessed using a questionnaire. Frailty and physical function were assessed by the kinesiologist at baseline and postintervention prior to hospital discharge.

Methods:

The study was a single-arm pilot intervention examining feasibility and preliminary efficacy. Kidney inpatients requiring dialysis were recruited to an individualized in-hospital physical activity intervention for the duration of their hospital stay. The intervention was led by a kinesiologist and supported by the clinical care team, including physiotherapists and nurse clinicians. Individualized exercise programs were created for patients to perform daily during their stay. These programs focused on strength, mobility, balance, and general movement and were tailored to each patient’s needs.

Results:

Thirty-six percent of eligible patients (n = 23/64) consented to participate in the Move More study, of whom 78% (n = 18/23) completed the intervention. The a priori level for consent to participate in the intervention was set at 60%. In addition, the a priori level for completion of assessments pre and postintervention was 50%. Ninety-five percent (n = 22/23) of preintervention assessments were completed compared to 65% of postintervention assessments. All participants who completed the survey (100%, n = 14/14) and most of the staff (77%, n = 24/31) reported being satisfied or very satisfied with the program. There were no adverse events related to the intervention. On average, Move More patients demonstrated improvements in frailty status and specific subsets of quality of life.

Limitations:

Firstly, as a feasibility study, the research was not powered to address the effectiveness of the intervention and lacked a comparison group to definitively link observed changes to the intervention itself. The voluntary nature of recruitment may have been biased toward ESKD inpatients with above-average motivation and baseline function. Furthermore, the small sample size from a single site limits the generalizability of findings. An additional limitation was the fact that postassessments were missed on a large number of patients, due to them being discharged prior to research staff knowing and being able to complete the assessments. Finally, studying the length of stay across the institution, as opposed to just the individual ward, would provide insight into hospitalization impact for these patients.

Conclusions:

The administration of and participation in a physical activity intervention for kidney inpatients requiring dialysis was initially not feasible primarily due to low recruitment and adherence challenges. The study was modified by including a research team member on the unit to increase recruitment efforts and support exercise adherence. The intervention impact includes potentially benefits on frailty and quality of life.

Physical Activity and Health-Related Quality of Life of Patients on Hemodialysis with Comorbidities: A Cross-Sectional Study

Patients on hemodialysis with multiple comorbidities have limited physical activity, resulting in poor health, low activity participation, and low quality of life. Accordingly, the nursing care provided to such patients should include regular physical activity training programs. Therefore, this cross-sectional descriptive study investigated whether patients on hemodialysis with and without comorbidities have different levels of physical activity and health-related quality of life (HRQoL); the correlations among the comorbidities, physical activity, and HRQoL of the two cohorts were also assessed. The 36-Item Short-Form Health Survey version 2 and International Physical Activity Questionnaire were employed to collect data from 120 patients on hemodialysis. An independent samples t-test and univariate and multivariate linear regression analyses were conducted. The overall HRQoL of patients with comorbidities was lower than that of patients without comorbidities (p = 0.008). Compared with patients who participated in low-intensity physical activity, the overall HRQoL of patients who participated in moderate-intensity physical activity was higher (p < 0.001). The overall HRQoL of patients with comorbidities who participated in low-intensity physical activity was lower than that of those who participated in moderate-intensity physical activity (p < 0.001). Moderate-intensity physical activity was correlated with higher HRQoL for patients with comorbidities. This finding supports the implementation of effective physical activity intervention measures. Furthermore, it supports the promotion of patient self-management and the implementation of regular exercise programs and lifestyle changes, and patients on hemodialysis can benefit from the future management of physical activities.

Efficacy of Tai Chi on Patients With Chronic Kidney Disease

Previous systematic reviews elucidate the efficacy of Tai Chi on the rehabilitation and treatment for various chronic diseases. Yet, no consensus has been reached on its efficacy and safety from those with chronic kidney disease (CKD). Therefore, we conducted a systematic review to critically summarize what is already known about the prevailing benefits of Tai Chi for CKD patients. There was no evidence that Tai Chi had adverse effects on CKD patients. Long-term Tai Chi exercises could improve quality of life, cardiorespiratory fitness, and physical motor function for the end-stage renal disease (ERSD) patients undergoing dialysis. Regular Tai Chi exercises might exert modest influences in delaying CKD progression for mild-moderate CKD patients. However, there is insufficient evidence to demonstrate positive effects of Tai Chi exercises on bone health of the ESRD patients. Accordingly, rigorously designed, longer-term studies of Tai Chi are warranted to identify its efficacy on CKD patients across different stages, especially targeting potential mechanisms in terms of Tai Chi altering biological gene profile expressions.

Emerging Patient-Centered Concepts in Pain Among Adults With Chronic Kidney Disease, Maintenance Dialysis, and Kidney Transplant

Patient reports of moderate to severe pain are common across the spectrum of chronic kidney disease. The synergistic effects of comorbid depression and anxiety can lead to maladaptive coping responses to pain, namely pain catastrophizing and illness-related post-traumatic stress disorder. If underlying depression and anxiety and associated maladaptive coping responses are not treated, patients can experience an increased perception of pain, worsened disability, decreased quality of life, withdrawal from social activities, and increased morbidity and mortality. Meanwhile, interest in nonpharmacologic treatments for pain that targets coping as well as comorbid anxiety and depression has been increasing, particularly given the significant societal damage that has resulted from the opioid epidemic. Evidence-based, nonpharmacologic treatments have shown promise in treating pain in areas outside of nephrology. Currently, little is known about the effects of these treatments among adults with CKD, and particularly end-stage kidney disease, when chronic pain can become debilitating. In this review, we examine patient-centered concepts related to pain that have received little attention in the nephrology literature. We also describe emerging areas of research, including omics technologies for biomarker discovery and advanced symptom clustering methods for symptom phenotyping, which may be useful to future kidney disease research and treatment.

Effectiveness and safety of rehabilitation on minimal change nephrotic syndrome in remission for elderly patients with low activity of daily living: a case report

There are few reports on the rehabilitation of elderly patients with minimal change nephrotic syndrome (MCNS). The purpose of this case study was to evaluate the efficacy and safety of rehabilitation for an elderly patient with MCNS in remission. The patient was an 86-year-old woman. She was admitted to the hospital with a diagnosis of MCNS, and steroid treatment was initiated. She was weaned from dialysis 2 weeks later; however, her activities of daily living (ADL) decreased, and she developed disuse syndrome. After rehabilitation, the patient's ADL, maximum hand grip strength, and gait function improved. There was no recurrence of weight gain or increased proteinuria during rehabilitation, but the estimated glomerular filtration rate decreased. This case suggests that rehabilitation for elderly patients with MCNS in remission can be effective for physical and ADL functions without relapse of MCNS. The effect of exercise therapy on the relationship between exercise therapy and renal function needs to be further investigated by collecting more cases.

Association of physical function and performance with peak VO2 in elderly patients with end stage kidney disease

BACKGROUND

Physical function is impaired in end stage renal disease (ESRD). Various instruments have been used to assess the functional capabilities and health status of patients with ESRD, but it is not known which has the best association with peak VO₂.

AIMS

To assess the association between functional measures in ESRD.

METHODS

Thirty nine elderly ESRD patients were evaluated with commonly used functional, health status, and quality of life measures, including maximal cardiopulmonary exercise testing (CPET), 6-min walk (6MWT), sit-to-stand test (STS), Veterans Specific Activity Questionnaire (VSAQ), upper and lower body strength, pulmonary function tests, and body composition determined by dual X-ray absorptiometry. The association between performance on these functional tools, clinical variables, and exercise test responses was assessed, and a non-exercise test multivariate model was developed to predict peak VO₂.

RESULTS

Peak VO₂ was modestly related to VSAQ score (r = 0.59, p < 0.01), indices of upper and lower body strength (r = 0.45, p < 0.01 for both), and FEV₁ (r = 0.51, p < 0.01). Functional and quality of life questionnaires were generally poorly related to one another and to peak VO₂. In a multivariate model, 6MWT performance, forced expiratory volume in 1 s (FEV₁), and VSAQ score were the best predictors of peak VO₂, yielding a multiple R = 0.82, accounting for 67% of the variance in peak VO₂.

CONCLUSION

Exercise capacity can be reasonably estimated using non-exercise test variables in patients with ESRD, including a symptom questionnaire (VSAQ), 6MWT and FEV₁.

CLINICAL TRIAL INFORMATION

ClinicalTrials.gov identifier: NCT01990495. Registered Nov 21, 2013.

Chronic kidney disease

Chronic kidney disease is a progressive disease with no cure and high morbidity and mortality that occurs commonly in the general adult population, especially in people with diabetes and hypertension. Preservation of kidney function can improve outcomes and can be achieved through non-pharmacological strategies (eg, dietary and lifestyle adjustments) and chronic kidney disease-targeted and kidney disease-specific pharmacological interventions. A plant-dominant, low-protein, and low-salt diet might help to mitigate glomerular hyperfiltration and preserve renal function for longer, possibly while also leading to favourable alterations in acid-base homoeostasis and in the gut microbiome. Pharmacotherapies that alter intrarenal haemodynamics (eg, renin-angiotensin-aldosterone pathway modulators and SGLT2 [SLC5A2] inhibitors) can preserve kidney function by reducing intraglomerular pressure independently of blood pressure and glucose control, whereas other novel agents (eg, non-steroidal mineralocorticoid receptor antagonists) might protect the kidney through anti-inflammatory or antifibrotic mechanisms. Some glomerular and cystic kidney diseases might benefit from disease-specific therapies. Managing chronic kidney disease-associated cardiovascular risk, minimising the risk of infection, and preventing acute kidney injury are crucial interventions for these patients, given the high burden of complications, associated morbidity and mortality, and the role of non-conventional risk factors in chronic kidney disease. When renal replacement therapy becomes inevitable, an incremental transition to dialysis can be considered and has been proposed to possibly preserve residual kidney function longer. There are similarities and distinctions between kidney-preserving care and supportive care. Additional studies of dietary and pharmacological interventions and development of innovative strategies are necessary to ensure optimal kidney-preserving care and to achieve greater longevity and better health-related quality of life for these patients.

Physical exercise and peritoneal dialysis: An area yet to be explored

Health-related quality of life (HRQoL) of patients suffering from chronic kidney disease (CKD) is profoundly impaired by their frailty, disability and decreased physical capacity. Especially among older patients, a high prevalence of low physical activity levels and reduced functional performance has been reported. Physical exercise training has been shown to have a beneficial impact, counteracting these same hazardous consequences of inactivity and sedentarism both on CKD and end-stage kidney disease (ESKD) patients on hemodialysis (HD) treatment. The evidence-based knowledge on the effects of physical exercise on ESKD patients undergoing Peritoneal Dialysis (PD) treatment is scarce, even though this is a continually growing population that shares the same risk factors and desired clinical outcomes as the previously mentioned groups of patients. Further investigation will be necessary to clarify whether this exercise-based approach may be suitable for the PD population. This paper's purpose is to review the available literature, including randomized controlled trials, reviews and meta-analysis results that assessed the impact of physical exercise on patients under PD treatment bearing in mind their HRQoL, physical functioning and cardiovascular parameters. Furthermore, it aims to evaluate the perceived significant barriers and limitations of the PD population in what concerns physical exercise practice and how nephrologists should address them.

Barriers and facilitators to exercise in haemodialysis patients: A systematic review of qualitative studies

AIMS

The purpose of this systematic review is to synthesize the results of qualitative research and to identify the barriers and facilitators to exercise in haemodialysis patients from the perspectives of haemodialysis patients, caregivers and dialysis staff members.

DESIGN

Systematic review of qualitative studies.

DATA SOURCES

Qualitative studies were extracted from MEDLINE, EMBASE, Web of Science, CINAHL, PsycINFO, PubMed, CBM, CNKI and WanFang Database from inception of each database until July 2020. Qualitative research and mixed method research including barriers and/or facilitators to exercise in haemodialysis patients were included.

REVIEW METHODS

The systematic search method SPIDER (sample, phenomenon of interest, design, evaluation, research type) was used. Thematic synthesis of qualitative data was used.

RESULTS

284 studies were screened and 10 studies published between 2007 and 2020 were finally included in this review. The review included 180 patients, 70 dialysis staff members and seven caregivers. Five analytical themes were identified: disease distress, perception of exercise, environmental restrictions, spirit strength and hospital management. Barriers include disease distress, perception of exercise (security issue), environmental restrictions and hospital management. Facilitators include perception of exercise (exercise being considered beneficial, preference for exercise) and spirit strength (from religious beliefs). It is the spiritual strength (from family and friends, from dialysis staff members) that is both the barrier and the facilitator.

CONCLUSION

There are many barriers in popularizing exercise among haemodialysis patients. Future intervention measures and health policies should strengthen the facilitators and reduce the barriers, so as to promote the clinical practice of exercise for haemodialysis patients.

IMPACT

This review summarizes the barriers and facilitators to exercise in haemodialysis patients. The results of this study have an impact on research, practice and health policy setting. The exercise level of haemodialysis patients can be improved by using the facilitators and solving the barriers.

Severity of protein-energy wasting and obesity are independently related with poor quality of life in peritoneal dialysis patients

Protein-energy wasting (PEW) and poor health-related quality of life (HRQoL) are independently associated with morbi-mortality in continuous ambulatory peritoneal dialysis (CAPD). PEW may reduce HRQoL; however, we hypothesized HRQoL is affected differentially by PEW degrees or by individual criteria of nutritional status. AIM: To evaluate HRQoL according to PEW severity and nutritional status indicators in CAPD. This is a cross-sectional study in 151 patients. Subjective global assessment (SGA) was employed, and nutritional status classified as normal, mild-moderate PEW, and severe PEW. HRQoL was evaluated using Kidney Disease Quality of Life Short Form™, including physical (PCS), mental (MCS) and kidney disease (KDCS) components, and their subscales. Dietary intake, anthropometric and biochemical variables were measured. Forty-six percent of patients were well-nourished, 44% had mild-moderate PEW, and 10% severe PEW. Compared with well-nourished patients, those with mild-moderate (p=0.06) and severe (p=0.005) PEW had lower HRQoL score [68 (52-75), 55 (45-72), 46 (43-58), respectively]. PCS, MCS, and KDCS and their subscales had lower values as PEW was more severe. Patients with obesity and hypoalbuminemia had significantly lower HRQoL overall and component scores than their counterparts. Dietary intake was not associated with quality of life. In multivariate analysis obesity, PEW (by SGA), hypoalbuminemia, and low educational level predicted poor HRQoL (χ2 58.2, p<0.0001). As conclusion, PEW severity was related with worse HRQoL, either as overall score or in every component or subscale in CAPD patients. Poor HRQoL was predicted independently by PEW severity and obesity; additional predictors were hypoalbuminemia and low education.

Improving dialysis adequacy and quality of life in patients undergoing hemodialysis with twice a week range of motion exercise

The study aimed to determine the effects of giving range of motion (ROM) twice a week as a form intradialytic exercise on patients' dialysis adequacy and quality of life. A total of 48 eligible participants were recruited and completed this study. The intervention group (n = 24) received twice a week ROM exercise over a 4 weeks period. The outcomes were assessed at pretest and at the end of the intervention. The study shows that ROM exercise was effective in improving dialyis adequacy that include ureum retention ratio (p= 0.027) and Kt/V (p= 0.017). Quality of life improved significantly particularly in the domains of symptom and effect of kidney disease. Integrating ROM into dialysis care shows as a potential intervention to improve dialysis adequacy and quality of life for patients undergoing hemodialysis. Future research should evaluate its efficacy using a randomized clinical trial design and larger sample of patients.

A Mediterranean lifestyle is associated with favourable cardiometabolic markers in people with non-dialysis dependent chronic kidney disease

Adherence to a Mediterranean lifestyle may be a useful primary and secondary prevention strategy for chronic kidney disease (CKD). This cross-sectional study aimed to explore adherence to a Mediterranean lifestyle and its association with cardiometabolic markers and kidney function in 99 people aged 73⋅2 ± 10⋅5 years with non-dialysis dependant CKD (stages 3-5) at a single Australian centre. Adherence was assessed using an a priori index, the Mediterranean Lifestyle (MEDLIFE) index. Cardiometabolic markers (total cholesterol, LDL-cholesterol, HbA1c and random blood glucose) and kidney function (estimated GFR) were sourced from medical records and blood pressure measured upon recruitment. Overall, adherence to a Mediterranean lifestyle was moderate to low with an average MEDLIFE index score of 11⋅33 ± 3⋅31. Adherence to a Mediterranean lifestyle was associated with employment (r 0⋅30, P = 0⋅004). Mediterranean dietary habits were associated with cardiometabolic markers, such as limiting sugar in beverages was associated with lower diastolic blood pressure (r 0⋅32, P = 0⋅002), eating in moderation with favourable random blood glucose (r 0⋅21, P = 0⋅043), having more than two snack foods per week with HbA1c (r 0⋅29, P = 0⋅037) and LDL-cholesterol (r 0⋅41, P = 0⋅002). Interestingly, eating in company was associated with a lower frequency of depression (χ2 5⋅975, P = 0⋅015). To conclude, Mediterranean dietary habits were favourably associated with cardiometabolic markers and management of some comorbidities in this group of people with non-dialysis dependent CKD.

Exercise programme to improve quality of life for patients with end-stage kidney disease receiving haemodialysis: the PEDAL RCT

BACKGROUND

Whether or not clinically implementable exercise interventions in haemodialysis patients improve quality of life remains unknown.

OBJECTIVES

The PEDAL (PrEscription of intraDialytic exercise to improve quAlity of Life in patients with chronic kidney disease) trial evaluated the clinical effectiveness and cost-effectiveness of a 6-month intradialytic exercise programme on quality of life compared with usual care for haemodialysis patients.

DESIGN

We conducted a prospective, multicentre randomised controlled trial of haemodialysis patients from five haemodialysis centres in the UK and randomly assigned them (1 : 1) using a web-based system to (1) intradialytic exercise training plus usual-care maintenance haemodialysis or (2) usual-care maintenance haemodialysis.

SETTING

The setting was five dialysis units across the UK from 2015 to 2019.

PARTICIPANTS

The participants were adult patients with end-stage kidney disease who had been receiving haemodialysis therapy for > 1 year.

INTERVENTIONS

Participants were randomised to receive usual-care maintenance haemodialysis or usual-care maintenance haemodialysis plus intradialytic exercise training.

MAIN OUTCOME MEASURES

The primary outcome of the study was change in Kidney Disease Quality of Life Short Form, version 1.3, physical component summary score (from baseline to 6 months). Cost-effectiveness was determined using health economic analysis and the EuroQol-5 Dimensions, five-level version. Additional secondary outcomes included quality of life (Kidney Disease Quality of Life Short Form, version 1.3, generic multi-item and burden of kidney disease scales), functional capacity (sit-to-stand 60 and 10-metre Timed Up and Go tests), physiological measures (peak oxygen uptake and arterial stiffness), habitual physical activity levels (measured by the International Physical Activity Questionnaire and Duke Activity Status Index), fear of falling (measured by the Tinetti Falls Efficacy Scale), anthropometric measures (body mass index and waist circumference), clinical measures (including medication use, resting blood pressure, routine biochemistry, hospitalisations) and harms associated with intervention. A nested qualitative study was conducted.

RESULTS

We randomised 379 participants; 335 patients completed baseline assessments and 243 patients (intervention, n = 127; control, n = 116) completed 6-month assessments. The mean difference in change in physical component summary score from baseline to 6 months between the intervention group and control group was 2.4 arbitrary units (95% confidence interval -0.1 to 4.8 arbitrary units; p = 0.055). Participants in the intervention group had poor compliance (49%) and very poor adherence (18%) to the exercise prescription. The cost of delivering the intervention ranged from £463 to £848 per participant per year. The number of participants with harms was similar in the intervention (n = 69) and control (n = 56) groups.

LIMITATIONS

Participants could not be blinded to the intervention; however, outcome assessors were blinded to group allocation.

CONCLUSIONS

On trial completion the primary outcome (Kidney Disease Quality of Life Short Form, version 1.3, physical component summary score) was not statistically improved compared with usual care. The findings suggest that implementation of an intradialytic cycling programme is not an effective intervention to enhance health-related quality of life, as delivered to this cohort of deconditioned patients receiving haemodialysis.

FUTURE WORK

The benefits of longer interventions, including progressive resistance training, should be confirmed even if extradialytic delivery is required. Future studies also need to evaluate whether or not there are subgroups of patients who may benefit from this type of intervention, and whether or not there is scope to optimise the exercise intervention to improve compliance and clinical effectiveness.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN83508514.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 40. See the NIHR Journals Library website for further project information.

Renal Rehabilitation: Exercise Intervention and Nutritional Support in Dialysis Patients

With the growing number of dialysis patients with frailty, the concept of renal rehabilitation, including exercise intervention and nutrition programs for patients with chronic kidney disease (CKD), has become popular recently. Renal rehabilitation is a comprehensive multidisciplinary program for CKD patients that is led by doctors, rehabilitation therapists, diet nutritionists, nursing specialists, social workers, pharmacists, and therapists. Many observational studies have observed better outcomes in CKD patients with more physical activity. Furthermore, recent systematic reviews have shown the beneficial effects of exercise intervention on exercise tolerance, physical ability, and quality of life in dialysis patients, though the beneficial effect on overall mortality remains unclear. Nutritional support is also fundamental to renal rehabilitation. There are various causes of skeletal muscle loss in CKD patients. To prevent muscle protein catabolism, in addition to exercise, a sufficient supply of energy, including carbohydrates, protein, iron, and vitamins, is needed. Because of decreased digestive function and energy loss due to dialysis treatment, dialysis patients are recommended to ingest 1.2-fold more protein than the regular population. Motivating patients to join in activities is also an important part of renal rehabilitation. It is essential for us to recognize the importance of renal rehabilitation to maximize patient satisfaction.

A Physical Activity Intervention Feasibility Study for Kidney Inpatients: A Basic Research Protocol

Background:

Low physical activity levels and poor physical functioning are strongly associated with poor clinical outcomes and mortality in adult kidney failure patients, regardless of treatment modality. Compared with the general population, individuals with chronic kidney disease are physically inactive, have reduced physical abilities and difficulties performing routine daily tasks, lower health-related quality of life, and higher cardiovascular morbidity and mortality. In addition, frail kidney failure patients have higher hospitalization and mortality rates as compared with other kidney failure patients. Evidence suggests that assessment and recommendations for physical activity should be part of standard care for kidney failure patients. Structured exercise can improve physical function and quality of life in frail older adults and may be used specifically for management of frailty in kidney failure. However, research is needed to determine best practices for implementation of physical function measurements and physical activity promotion in standard kidney failure care.

Objective:

The proposed Move More study will assess the feasibility of a physical activity intervention offered to the kidney failure inpatients in Calgary, Alberta. Specifically, this study is designed to examine the effects of an early physical activity/mobility intervention led by a kinesiologist, and supported by the clinical care team including physiotherapists (PT) and nurse clinicians.

Methods:

The Move More study is a single-arm pilot intervention examining feasibility and optimal improvement in real-world conditions. Kidney failure inpatients at the Foothills Medical Centre will be recruited to participate. Patients will receive an individualized in-hospital physical activity/mobility intervention. Frailty and physical function will be assessed at baseline and postintervention prior to hospital discharge. The goal is to recruit 24 to 36 patients.

Conclusions:

Evidence needed to support the inclusion of mobility and physical activity as part of standard care will be gathered, with knowledge gained used to help direct future physical activity programming for kidney failure inpatients.

Efficacy of aerobic exercise on the cardiometabolic and renal outcomes in patients with chronic kidney disease: a systematic review of randomized controlled trials

BACKGROUND

Several randomized controlled trials (RCTs) have demonstrated the cardiometabolic effects of aerobic exercise in the general population and in patients with cardiovascular diseases. However, the efficacy of aerobic exercise in patients with chronic kidney disease (CKD) remains to be elucidated.

METHODS

RCTs comparing aerobic exercise with no aerobic exercise in patients with CKD not requiring kidney replacement therapy were identified through PubMed using RobotAnalyst, a web-based software system that combines text-mining and machine learning algorithms for organizing references. Cardiometabolic and renal outcomes of interest included body mass index (BMI); systolic blood pressure (SBP); hemoglobin A1c (HbA1c), total cholesterol (TCHO), low- and high- density lipoprotein cholesterol (LDLC and HDLC, respectively), and urinary protein (UP) levels/concentration; peak oxygen uptake (Vo2peak); and glomerular filtration rate (GFR) at the end of the follow-up period. The standardized mean difference (SMD) of each outcome was estimated using the DerSimonian-Laird random-effect model with inverse-variance weighting.

RESULTS

A total of 15 trials, including 622 patients, were included. Their follow-up periods were 3-4, 6-12, and > 12-months in 7 (46.7%), 7 (46.7%), and 1 (6.7%) trial(s), respectively. Meta-analyses showed that aerobic exercise significantly decreased BMI (SMD, -0.19 [95% confidence interval, -0.38, -0.00]) and SBP (-0.75 [-1.24, -0.26]) and increased Vo2peak (0.54 [0.29, 0.78]); however, no significant association was observed in HbA1c, TCHO, HDLC, LDLC, GFR, and UP. Meta-regression models suggested that aerobic exercise was more likely to improve Vo2peak in patients with younger age, no diabetes, and lower BMI.

CONCLUSION

Aerobic exercise of 3-12 months' duration improved obesity, high blood pressure, and low exercise capacity in overweight/obese patients with CKD, but it had no significant effect on GFR and proteinuria. Well-designed large RCTs with a longer follow-up period are needed to evaluate the efficacy of aerobic exercise in patients with CKD.

Exercise training in dialysis patients: impact on cardiovascular and skeletal muscle health

Dialysis patients show a high rate of reduced functional capacity, morbidity and mortality. Cardiovascular disorders, muscle atrophy and malnutrition play an essential role among the aetiological factors. Sedentary lifestyle characterizes them and contributes to the aggravation of the disorders. On the contrary, exercise training is an important preventive and therapeutic tool both for cardiovascular problems and for the appearance of muscle atrophy in dialysis patients. Regular exercise causes both central (cardiac) and peripheral (muscular) adaptations, improving functional capacity. In particular, circulatory system clinical trials in haemodialysis (HD) patients documented that exercise has favourable effects on heart function, promotes balance on the cardiac autonomic nervous system and contributes to the management of arterial hypertension. In the muscular system, it prevents muscle atrophy or contributes significantly to its treatment. The main preventive mechanisms of the beneficial effect of exercise on the muscles constitute the inhibition of the apoptotic processes and protein degradation. Exercise training in HD patients leads to an increase of muscle fibers, mitochondria and capillaries, and the combination of regular exercise and dietary strategies is even more effective in preventing or treating muscle atrophy. Finally, an improvement in functional capacity and quality of life was found also in peritoneal dialysis patients following exercise training.

Respiratory muscle strength and quality of life in chronic kidney disease patients undergoing hemodialysis

Abstract Introduction: Hemodialysis (HD) sessions associated with the chronic kidney disease (CKD) repercussions may cause respiratory muscle impairment and limitations of daily living activities, which may compromise the quality of life. Objective: To evaluate respiratory muscle strength and quality of life in HD patients. Methods: A cross-sectional study involving CKD patients of both sexes undergoing HD. All were evaluated during HD, using an evaluation form containing personal and clinical data, presence of comorbidities, lifestyle (including self-reported physical activity) and vital signs. Respiratory muscle strength was analyzed by maximum inspiratory (MIP) and maximum expiratory (MEP) pressures by manovacuometer and quality of life using the SF-36 questionnaire. Results: Sixty-eight patients were evaluated (69.1% men), with a mean age of 54.9 ± 13.6 years. The MEP% was below of predicted (79.5 ± 25.7) and the MIP% was reduced only in women (77.8 ± 38.7). The MIP% was related to CKD time (p = 0.04) in men. The SF-36 domain that showed the most impairment was physical limitation [25.0 (13.0-67.0)], while mental health was the least impaired domain [72.0 (62.0-84.0)]. Those who reported the practice of physical activity obtained better results in vitality domain (p = 0.01). In the analysis stratified by sex, the functional capacity domain was less compromised in men who practiced self-reported physical activity (p = 0.02). Conclusion: CKD patients undergoing HD had a reduction in MEP relative to predicted, in addition to a greater impairment of MIP in men with longer CKD time and in women alone, although the clinical relevance of this finding is uncertain. Quality of life was more compromised in the physical limitation domain, where those who self-reported physical activity achieved better results in the domains of vitality (total sample) and functional capacity (men).

Exergaming for Quality of Life in Persons Living with Chronic Diseases: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate the evidence of effectiveness of exergame-based rehabilitative interventions on health-related quality of life (HRQoL) in persons with chronic diseases. TYPE: Systematic review and meta-analysis.

LITERATURE SURVEY

Randomized and nonrandomized controlled trials of exergame rehabilitation interventions in populations with chronic diseases reporting HRQoL outcomes were identified by searching PubMed, Scopus, Physiotherapy Evidence Database (PEDro), Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar, using keywords and MeSH terms for papers published between January 2005 and March 2019.

METHODOLOGY

Risk of bias was assessed by using the PEDro scale. The Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system was used to score the quality of evidence. Pooled effects were reported as standardized mean differences (SMDs) or weighted mean difference (MDs) and 95% confidence intervals (CIs), using a random-effects model. Heterogeneity was weighted by inconsistency I² tests.

SYNTHESIS

Thirty-four trials were identified (1594 participants). Overall, the evidence was low quality. Exergames significantly improved HRQoL in populations with chronic diseases, with a small effect size (32 studies; 1544 participants; SMD 0.24; 95% CI 0.1 to 0.4; I²  = 27%) and specifically in people with neurological disorders (20 studies, 956 participants, SMD 0.22; 95% CI 0.2 to 0.4; I²  = 49%), rheumatologic diseases (four studies, 210 participants, SMD 0.39; 95% CI 0.1 to 0.7; I²  = 4%), and cardiorespiratory and chronic metabolic conditions (five studies, 309 participants, SMD 0.23; 95% CI 0.0 to 0.5; I²  = 0%). Exergaming interventions in health care settings demonstrated similarly small but positive effects (22 studies, 905 participants, SMD 0.30; 95% CI 0.1 to 0.5; I²  = 41%), whereas those carried out in home-based contexts did not.

CONCLUSIONS

Exergame-based rehabilitative interventions performed in health care settings led to small but statistically significant improvements in HRQoL in persons with chronic diseases.

Green nephrology and eco-dialysis: a position statement by the Italian Society of Nephrology

High-technology medicine saves lives and produces waste; this is the case of dialysis. The increasing amounts of waste products can be biologically dangerous in different ways: some represent a direct infectious or toxic danger for other living creatures (potentially contaminated or hazardous waste), while others are harmful for the planet (plastic and non-recycled waste). With the aim of increasing awareness, proposing joint actions and coordinating industrial and social interactions, the Italian Society of Nephrology is presenting this position statement on ways in which the environmental impact of caring for patients with kidney diseases can be reduced. Due to the particular relevance in waste management of dialysis, which produces up to 2 kg of potentially contaminated waste per session and about the same weight of potentially recyclable materials, together with technological waste (dialysis machines), and involves high water and electricity consumption, the position statement mainly focuses on dialysis management, identifying ten first affordable actions: (1) reducing the burden of dialysis (whenever possible adopting an intent to delay strategy, with wide use of incremental schedules); (2) limiting drugs and favouring "natural" medicine focussing on lifestyle and diet; (3) encouraging the reuse of "household" hospital material; (4) recycling paper and glass; (5) recycling non-contaminated plastic; (6) reducing water consumption; (7) reducing energy consumption; (8) introducing environmental-impact criteria in checklists for evaluating dialysis machines and supplies; (9) encouraging well-planned triage of contaminated and non-contaminated materials; (10) demanding planet-friendly approaches in the building of new facilities.

"Celebrating old age": an obsolete expression during the COVID-19 pandemic? Medical, social, psychological, and religious consequences of home isolation and loneliness among the elderly

Since epidemiological arguments favouring self-isolation during the COVID-19 pandemic are widely recommended, the consequences of social isolation/loneliness of older people considered to be at higher risk for severe illness are neglected. We identified and described medical, social, psychological, and religious issues, indirectly generated by the COVID-19 lockdown. Mortality induced by SARS-CoV-2 and death from other "neglected" issues were put in balance. Arguments for strict lockdown from most European countries are compared with a relaxed approach, as has been applied in Sweden. Social isolation affects disproportionally the elderly, transforming it into a public health concern. One witnesses openly ageist discourse, while painful decisions to prioritising ventilation for younger patients deepens the sense of hopelessness. Fear has led to anxiety disorders and depression. Various religious practices provide resources for coping with isolation/overcoming loneliness. Higher levels of mortality/morbidity due to "COVID-19 versus non-COVID-19" polarisation oblige the healthcare community to find ways to provide proper care for its elders.