Benefits of exercise training in patients on continuous ambulatory peritoneal dialysis

Subjective cognitive complaints in end-stage renal disease: a systematic review and meta-analysis

Cognitive impairment is common in patients with end-stage renal disease (ESRD) and is associated with compromised quality of life and functional capacity, as well as worse clinical outcomes. Most previous research and reviews in this area were focused on objective cognitive impairment, whereas patients' subjective cognitive complaints (SCCs) have been less well-understood. This systematic review aimed to provide a broad overview of what is known about SCCs in adult ESRD patients. Electronic databases were searched from inception to January 2022, which identified 221 relevant studies. SCCs appear to be highly prevalent in dialysis patients and less so in those who received kidney transplantation. A random-effects meta-analysis also shows that haemodialysis patients reported significantly more SCCs than peritoneal dialysis patients (standardised mean difference -0.20, 95% confidence interval -0.38 to -0.03). Synthesis of longitudinal studies suggests that SCCs remain stable on maintenance dialysis treatment but may reduce upon receipt of kidney transplant. Furthermore, SCCs in ESRD patients have been consistently associated with hospitalisation, depression, anxiety, fatigue, and poorer quality of life. There is limited data supporting a strong relation between objective and subjective cognition but preliminary evidence suggests that this association may be domain-specific. Methodological limitations and future research directions are discussed.

Cardiopulmonary exercise testing in patients with end-stage kidney disease: principles, methodology and clinical applications of the optimal tool for exercise tolerance evaluation

Chronic kidney disease (CKD), especially end-stage kidney disease (ESKD), is associated with an increased risk for cardiovascular events and all-cause mortality. Exercise intolerance as well as reduced cardiovascular reserve is extremely common in patients with CKD. Cardiopulmonary exercise testing (CPET) is a non-invasive, dynamic technique that provides an integrative evaluation of cardiovascular, pulmonary, neuropsychological and metabolic function during maximal or submaximal exercise, allowing the evaluation of functional reserves of these systems. This assessment is based on the principle that system failure typically occurs when the system is under stress and thus CPET is currently considered to be the gold standard for identifying exercise limitation and differentiating its causes. It has been widely used in several medical fields for risk stratification, clinical evaluation and other applications, but its use in everyday practice for CKD patients is scarce. This article describes the basic principles and methodology of CPET and provides an overview of important studies that utilized CPET in patients with ESKD, in an effort to increase awareness of CPET capabilities among practicing nephrologists.

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.

Exercise or physical activity-related adverse events in people receiving peritoneal dialysis: A systematic review

People receiving peritoneal dialysis (PD) may benefit from participation in exercise or physical activity. However, exercise therapy for people receiving PD is not typically included in routine care, in part, due to ongoing uncertainties about risk. The aim of this review was to systematically collate and explore data on adverse events experienced by people receiving PD while undertaking an exercise or physical activity intervention. Searches yielded 25 exercise or physical activity intervention studies involving people receiving PD. Of these 25 studies, 17 studies provided adverse event data and were included in the final review. No serious adverse events (e.g. death, hospitalisation) were found attributable to the intervention. From 50 reported adverse events during the intervention period, 32 were attributable to the exercise or physical activity intervention with most being musculoskeletal (e.g. muscle/joint pain, etc.) followed by fatigue. Most events were mild to moderate in severity and resolved by exercise programme modification, education, rest or medication. The results from this review did not uncover signals of harm for people receiving PD who engage in exercise with risk of adverse events appearing to be low, however, improved adverse events reporting and further interventional studies are required before robust guidelines can be produced.

Effects of Baduanjin Exercise on Physical Function and Health-Related Quality of Life in Peritoneal Dialysis Patients: A Randomized Trial

Background and Aims: Exercise is an efficient non-pharmacological intervention for chronic kidney disease. The study aims to evaluate the effects of Baduanjin exercise on physical function and health-related quality of life (HRQOL) in peritoneal dialysis (PD) patients. Methods: Seventy PD patients were randomly assigned to either the Baduanjin exercise group or the control group. Fifty-seven patients completed the study (exercise group, 25; control group, 32). The exercise group received the Baduanjin exercise program for 12 weeks. The control group received usual care. Three well-established performance-based tests determined physical function: five times sit-to-stand test (FTSST), timed up and go test (TUGT), and handgrip strength (HGS). HRQOL was assessed by the Kidney Disease Quality of Life-Short Form. Results: At baseline, no differences in physical function and HRQOL were observed between the Baduanjin exercise and the control group. At follow-up, the Baduanjin exercise group showed a marginally significant improvement in FTSST (P = 0.008) and TUGT (P = 0.040) over the 12 weeks compared to the control group. HRQOL in the Baduanjin exercise group was significantly higher than that of the control group. Conclusions: A 12-week Baduanjin exercise program may improve physical function and HRQOL in PD patients. Longer follow-up is needed to determine if these findings will translate into clinical application.

Physical activity and exercise in peritoneal dialysis: International Society for Peritoneal Dialysis and the Global Renal Exercise Network practice recommendations

Life participation requiring physical activity and physical function is a key patient-reported outcome for people receiving peritoneal dialysis (PD). Clinician guidance is required from multidisciplinary sources regarding exercise and activity advice to address the specific needs of this group. From August 2020 through to June 2021, the Global Renal Exercise Network and the International Society for Peritoneal Dialysis reviewed the published literature and international clinical experience to develop a set of clinical practice points. A set of questions relevant to physical activity and exercise were developed from the perspective of a person receiving PD and were the basis for the practice point development. The GRADE framework was used to evaluate the quality of evidence and to guide clinical practice points. The review of the literature found sparse quality evidence, and thus the clinical practice points are generally based on the expert consensus of people receiving PD, PD exercise expert clinicians and experienced PD exercise researchers. Clinical practice points address timing of exercise and activity (post-catheter insertion, peritoneal space empty or full), the uptake of specific activities (work, sex, swimming, core exercise), potential adverse outcomes related to activity and exercise (exit site care, perspiration, cardiovascular compromise, fatigue, intra-abdominal pressure), the effect of exercise and activity on conditions of interest (mental health, obesity, frailty, low fitness) and exercise nutrition.

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.

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.

An Exercise Program for Peritoneal Dialysis Patients in the United States: A Feasibility Study

BACKGROUND

People with end-stage kidney disease receiving peritoneal dialysis (PD) are generally physically inactive and frail. Exercise studies in PD are scarce and currently there are no PD exercise programs in the United States. The primary objective of this study was to test the feasibility of a combined resistance and cardiovascular exercise program for PD patients under the care of a dedicated home dialysis center in the United States.

STUDY DESIGN

Parallel randomized controlled feasibility study.

SETTING & PARTICIPANTS

PD patients were recruited from a single center and randomly assigned to the intervention (exercise; n = 18) or control (nonexercise; n = 18) group.

INTERVENTION

The intervention group received monthly exercise physiologist consultation, exercise prescription (resistance and aerobic exercise program using exercise bands), and 4 exercise support telephone calls over 12 weeks. The control group received standard care.

OUTCOMES

The primary outcome was study feasibility as measured by eligibility rates, recruitment rates, retention rates, adherence rates, adverse events, and sustained exercise rates. Secondary outcome measures were changes in physical function (sit-to-stand test, timed-up-and-go test, and pinch-strength tests) and patient-reported outcome measures.

RESULTS

From a single center with 75 PD patients, 57 (76%) were deemed eligible, resulting in a recruitment rate of 36 (63%) patients. Participants were randomly assigned into 2 groups of 18 (1:1). 10 patients discontinued the study (5 in each arm), resulting in 26 (72%) patients, 13 in each arm, completing the study. 10 of 13 (77%) intervention patients were adherent to the exercise program. A t test analysis of covariance found a difference between the treatment groups for the timed-up-and-go test (P = 0.04) and appetite (P = 0.04). No serious adverse events caused by the exercise program were reported.

LIMITATIONS

Single center, no blinded assessors.

CONCLUSIONS

A resistance and cardiovascular exercise program appears feasible and safe for PD patients. We recommend that providers of PD therapy consider including exercise programs coordinated by exercise professionals to reduce the physical deterioration of PD patients.

FUNDING

None.

TRIAL REGISTRATION

NCT03980795.

Prescribing peritoneal dialysis and achieving good quality dialysis in low and low-middle income countries

The provision of long-term renal replacement therapies for patients with end-stage kidney disease (ESKD) in low and low-middle income countries (LLMICs) has been a pervasive challenge, impeded mainly by monetary constraints, limited health-care resources, and geographical and logistic difficulties. Even for patients who could initiate dialysis, discontinuation of dialysis treatment due to the lack of financial sustainability is a valid concern. While the delivery of high-quality dialysis should not be compromised in these settings, perpetuity on dialysis is of paramount consideration for these patients, with sustaining life being just as important as achieving clinical well-being. As intensification of peritoneal dialysis (PD) prescription comes with immense cost in these settings, the strategy for stretching affordability of dialysis involves optimizing the number of PD exchanges required or delaying the transition to a high PD dose of four bags per day of continuous ambulatory PD (CAPD) prescription. This can be accomplished through the use of low-cost adjunctive treatment, by preserving residual kidney function and adopting incremental PD. The use of expensive, complex, or inaccessible monitoring tools for peritoneal membrane function and dialysis clearance could be replaced by clinical assessment and widely available biochemical indicators, which will significantly reduce the investigation costs, with consequent savings that could allow for lengthening the duration of PD therapy. Finally, it is important for each PD program in LLMICs to monitor these outcome indicators, to ensure the consistent delivery of acceptable quality of PD to their patients.

Exercise and physical activity for people receiving peritoneal dialysis: Why not?

People with end-stage kidney disease (ESKD) receiving peritoneal dialysis (PD) are physically inactive leading to low physical function and poor health outcomes. Guidelines recommend that nephrologists encourage PD patients to increase their activity levels; however, PD patients are often discouraged from participating in exercise programs because of perceived barriers and a lack of precision about the appropriate exercise regimen. This review suggests ways forward to assist nephrology professionals to encourage PD patients to exercise, instead of creating barriers. The paper draws on the literature in addition to the experience of programs in France, the United States, and Australia to demonstrate the possibilities when considering increasing physical activity in this group.

Home-based Aerobic Exercise and Resistance Training in Peritoneal Dialysis Patients: A Randomized Controlled Trial

Potential effects of aerobic and resistance training in peritoneal dialysis (PD) patients have been partially elucidated. We investigated effects of a home-based exercise program on physical functioning and health-related quality of life (HRQOL) in PD patients. Patients were randomly assigned to exercise (n = 24) and usual care (n = 23) groups. The exercise patients performed aerobic exercise thrice weekly and resistance training twice weekly at home for 12 weeks. The usual care patients received no specific intervention. The distance in incremental shuttle walking test significantly improved in the exercise group compared with the usual care group (P = 0.02). Among the HRQOL subscales assessed using the Kidney Disease Quality of Life-Short Form questionnaire, kidney disease component summary (P = 0.03), physical role functioning (P = 0.01), emotional role functioning (P < 0.01), and role/social component summary (P < 0.01) significantly improved in the exercise group. Moreover, serum albumin was significantly maintained in the exercise group (P = 0.03). There were no reported adverse events associated with the intervention. To our knowledge, this is the first randomized controlled trial to indicate the beneficial effects of a 12-week home-based exercise program exclusively in PD patients.

Facilitators and Barriers to Exercise Influenced by Traditional Chinese Culture: A Qualitative Study of Chinese Patients Undergoing Hemodialysis

Introduction: Exercise is recommended for patients undergoing hemodialysis to decrease morbidity and mortality. However, their exercise level is lower than healthy people. Understanding reasons behind their sedentary lifestyle is required. Traditional Chinese culture may have a profound impact on patients’ perceptions of exercise, particularly with regard to the relationship of overwork and kidney function and family members’ attitudes toward patients’ participation in exercise. Therefore, we sought to explore the facilitators and barriers to exercise influenced by traditional Chinese culture. Methods: We conducted semistructured interviews with 44 Chinese patients residing in Nantong of Jiangsu Province undergoing hemodialysis, aged 25 to 77 years. Interview questions focused on their perceptions of, attitudes to, and experiences with exercise. Each interview was digitally recorded and lasted from 40 to 60 minutes. Conventional content analysis was used to understand facilitators and barriers to exercise within their experience and perceptions. Findings: We found that specific Chinese cultural health beliefs informed by traditional Chinese medicine strongly affected patients’ attitudes and behaviors toward exercise. Participants in this study tended to believe that overwork impairs kidney functions and viewed strenuous exercise as overwork. Although participants admitted the benefits of exercise, they rejected strenuous exercise and regarded nearly all modalities of exercise with or without facilities (except walking) as strenuous exercise. The most common barriers to exercise were lack of motivation, bad weather, negative attitudes of family members toward patients’ doing exercise, and insufficient exercise information resources. The most common facilitators found in this study were their increased physical well-being and confidence from exercise. Group exercise supported by family members and positive attitudes toward obtaining exercise information were also motivators. Discussion: Chinese patients undergoing hemodialysis reported more barriers than facilitators to exercise. Perceptions and attitudes toward exercise informed by traditional Chinese culture may be hidden barriers to exercising. Our findings indicated that culturally sensitive and patient-centered exercise interventions for Chinese patients are urgently needed.

Health-related quality of life in peritoneal dialysis patients: A narrative review

Health-related quality of life (HRQOL) is an important aspect of patients´ health that should be an integral part of the evaluation of patient-centered outcomes, not least because HRQOL associates with patients´ morbidity and mortality. This applies also to chronic kidney disease patients, including those dependent on renal replacement therapies, the type of which may influence patients´ perception of HRQOL. Several studies have addressed HRQOL in chronic kidney disease patients undergoing renal replacement therapies, especially transplanted patients and hemodialysis patients, while publications concerning peritoneal dialysis (PD) patients are scarcer. This review describes some of the methods used to assess HRQOL, factors influencing HRQOL in PD patients, HRQOL in PD vs hemodialysis, and the relation between HRQOL and patient outcomes. We conclude that assessment of HRQOL-often neglected at present-should be included as a standard measure of patient-centered outcomes and when monitoring the quality and effectiveness of renal care including PD treatment.

Virtual touch IQ elastography in evaluation of Achilles tendon in patients with chronic renal failure

PURPOSE

To evaluate the sonoelastographic changes in the Achilles tendon in patients with chronic renal failure (CRF) using virtual touch imaging quantification (VTIQ) elastography.

METHODS

Twenty-six patients undergoing three hemodialysis sessions per week and 26 subjects admitted to our institution between January 2016 and April 2016 were included in this prospective study. The characteristics and body mass index of the patients were noted. Ultrasonography was performed parallel to the long axis of the bilateral Achilles tendons during relaxation of the legs using the Siemens Acuson S3000™ ultrasound device (Siemens HealthCare, Erlangen, Germany). Tendon thickness was reviewed, and tissue stiffness was quantitatively assessed using VTIQ elastography. Independent samples t test and Mann-Whitney U test were used for statistical analyses.

RESULTS

The median values of shear wave velocities of the Achilles tendon in patients with CRF were 7.19 m/s (4.23-9.77 m/s) on the right and 6.98 m/s (4.00-9.82 m/s) on the left, while they were 5.11 m/s (4.09-8.82 m/s) on the right and 5.36 m/s (4.05-8.80 m/s) on the left in controls. The stiffness of the Achilles tendons in patients with CRF was found to be higher than that in controls (right: P < 0.001, left: P = 0.004). There was no statistically significant difference in tendon thickness between the CRF and control groups (P > 0.05).

CONCLUSION

The thickness and stiffness of tendon can be effectively evaluated with sonoelastography. The thickness of the Achilles tendon did not significantly differ between the patients with CRF and healthy subjects. However, the stiffness of the Achilles tendon measured with VTIQ elastography was demonstrated to be increased in the patients with CRF.

Physical Activity in Patients Treated With Peritoneal Dialysis: A Systematic Review and Meta-analysis

BACKGROUND

Exercise has been shown to be of benefit in the general population and in patients with chronic diseases. Despite a lack of compelling evidence, patients with end-stage kidney disease (ESKD) treated with peritoneal dialysis (PD) are often discouraged from participating in exercise programs that include weight lifting due to concerns about the development of hernias and leaks. The actual effects of physical activity with or without structured exercise programs for patients on PD remain unclear.

OBJECTIVE

To determine the risks and benefits of physical activity in the ESKD population treated with PD.

DESIGN

Systematic review and meta-analysis.

SETTING

Included all studies that met our criteria regardless of country of origin.

PATIENTS

Adult patients with ESKD treated with PD.

MEASUREMENTS

Descriptive and quantitative analysis of our primary and secondary outcome variables.

METHODS

We searched MEDLINE, Embase, CINAHL, and Cochrane Central Register of Controlled Trials for observational and interventional studies examining the effects of physical activity in patients on PD. A systematic review and meta-analysis was conducted of the identified studies. The primary outcomes of interest included patient-centered outcomes of mental health, physical functioning, fatigue, quality of life, and adverse events. Secondary outcomes included nutritional measures, lipid profile, blood pressure changes, maximum heart rate, resting heart rate, maximal oxygen consumption, muscle development, cognitive function, and markers of inflammation.

RESULTS

Of 1828 studies identified by the literature search, 12 met the inclusion criteria including 6 interventional and 6 observational studies. There was limited information on the patient important outcomes. However, there is some evidence for improvements in burden of kidney disease, physical function, and some mental health measures with physical activity.

LIMITATIONS

Lack of well-designed randomized controlled trials impaired our ability to determine the benefits and risks of increasing physical activity.

CONCLUSIONS

There is limited evidence of benefit with increased levels of physical activity in PD patients. Further research is needed to define the exercise program that is likely to be of most benefit to patients treated with PD.

Effects of Physical Exercise in Patients with End Stage Renal Failure, on Dialysis and Renal Transplantation: Current Status and Recommendations

There is increasing evidence about the benefits of regular physical activity in the chronically ill. Patients with chronic renal failure prior to and after renal transplant are one of the target groups in which increased controlled physical activity is highly recommended. Significant atrophy and increased non-contractile tissue are present in the muscle of predialytic and patients on hemodialysis, which is associated with poor physical performance and poor outcome of renal disease. Thus, interventions to increase physical activity or otherwise address atrophy may improve performance and quality of life in these patients. Other abnormalities in these patients, such as metabolic impairments, anemia, and hormonal changes, especially insulin resistance and lipid disorders, could be also modulated by certain therapeutic agents and physical activity. Increasing activity levels in this target group could be particularly important since it is well established that controlled physical exercise reduces the risk of cardiovascular disease in the general population. Patients who participate in regular physical activity following transplant will have higher health-related fitness and quality of life compared to those who remain inactive. The potential risk of physical activity can be reduced by medical evaluation, risk stratification, careful supervision, and education

Physical Function and Physical Activity in Peritoneal Dialysis Patients

BACKGROUND

Physical functioning (PF) and physical activity (PA) are low in patients treated with maintenance hemodialysis (MHD). Little information exists on this topic in patients treated with peritoneal dialysis (PD). The objective of this study was to compare PF and PA in patients with Stage-5 chronic kidney disease (CKD) treated with PD and in-center MHD.

METHODS

Physical functioning was measured in 45 prevalent PD patients using standard physical performance measures that include gait speed, chair stand, standing balance, 6-minute-walk, incremental shuttle walk and self-reported PF using the short form (SF)-36 questionnaire. Physical activity was determined from self-report and using the Community Healthy Activities Model Program for Seniors (CHAMPS) questionnaire. Scores for the short physical performance battery (SPPB) were calculated. In-center MHD patients were matched by age, gender, and diabetes status to the PD patients.

RESULTS

Unadjusted comparisons showed significantly higher 6-minute-walk distance, shuttle-walk distance and hand-grip in the PD patients. Adjustment in multiple regression analysis resulted in only gait speed being significantly different between the groups. All test results in both groups were lower than reference values for age and gender in the general population, and were at the levels indicating impairment. Physical activity was not different between the 2 groups (average age 49 yrs), and both groups had weekly caloric expenditure from all exercise and from moderate-intensity exercise that was similar to older (> 70 yrs) community-dwelling adults. Adjusted association indicated that PA was significantly associated with shuttle-walk distance.

CONCLUSIONS

Physical functioning and PA measures were low in both PD and MHD groups. Interventions to improve PA and PF should be strongly considered for both PD and MHD patients.

Metabolic syndrome and obesity in peritoneal dialysis

Metabolic syndrome (MS) refers to clustering of features related to increased risk of cardiovascular disease, which include obesity or central obesity, dyslipidemia, diabetes mellitus or insulin resistance, together with hypertension. The prevalence of MS in end-stage renal failure patients on peritoneal dialysis is quite common, ranging from 40% to 60%, depending on the population studied and the definition used. However, there are controversies about the clinical outcome of patients with MS, particularly in the area of obesity. Whether peritoneal dialysis predisposes patients to MS is another unsolved issue. Despite these controversies, preventing patients from developing MS is important, at least from a theoretical point of view.

Patient health and well-being while waiting for renal transplantation: part I

This is the first article in a series of three articles concerning renal transplantation. This first article will address the patient's health and well-being while waiting for renal transplantation and the role of the multidisciplinary team in the promoting of this. The subsequent articles will address pre- and post-renal transplant care and the long-term complications of renal transplantation.

Exercise training for adults with chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) is a worldwide public health problem. In the National Kidney Foundation Disease Outcomes Quality Initiative guidelines it is stressed that lifestyle issues such as physical activity should be seen as cornerstones of the therapy. The physical fitness in adults with CKD is so reduced that it impinges on ability and capacity to perform activities in everyday life and occupational tasks. An increasing number of studies have been published regarding health effects of various regular exercise programmes in adults with CKD and in renal transplant patients.

OBJECTIVES

We aimed to: 1) assess the effects of regular exercise in adults with CKD and kidney transplant patients; and 2) determine how the exercise programme should be designed (e.g. type, duration, intensity, frequency of exercise) to be able to affect physical fitness and functioning, level of physical activity, cardiovascular dimensions, nutrition, lipids, glucose metabolism, systemic inflammation, muscle morphology and morphometrics, dropout rates, compliance, adverse events and mortality.

SEARCH STRATEGY

We searched the Cochrane Renal Group's specialised register, CENTRAL, MEDLINE, EMBASE, CINAHL, Web of Science, Biosis, Pedro, Amed, AgeLine, PsycINFO and KoreaMed. We also handsearched reference lists of review articles and included studies, conference proceeding's abstracts. There were no language restrictions.Date of last search: May 2010.

SELECTION CRITERIA

We included any randomised controlled trial (RCT) enrolling adults with CKD or kidney transplant recipients undergoing any type of physical exercise intervention undertaken for eight weeks or more. Studies using less than eight weeks exercise, those only recommending an increase in physical activity, and studies in which co-interventions are not applied or given to both groups were excluded.

DATA COLLECTION AND ANALYSIS

Data extraction and assessment of study and data quality were performed independently by the two authors. Continuous outcome data are presented as standardised mean difference (SMD) or mean difference (MD) with 95% confidence intervals (CI).

MAIN RESULTS

Forty-five studies, randomising 1863 participants were included in this review. Thirty two studies presented data that could be meta-analysed. Types of exercise training included cardiovascular training, mixed cardiovascular and resistance training, resistance-only training and yoga. Some studies used supervised exercise interventions and others used unsupervised interventions. Exercise intensity was classed as 'high' or 'low', duration of individual exercise sessions ranged from 20 minutes/session to 110 minutes/session, and study duration was from two to 18 months. Seventeen per cent of studies were classed as having an overall low risk of bias, 33% as moderate, and 49% as having a high risk of bias.The results shows that regular exercise significantly improved: 1) physical fitness (aerobic capacity, 24 studies, 847 participants: SMD -0.56, 95% CI -0.70 to -0.42; walking capacity, 7 studies, 191 participants: SMD -0.36, 95% CI-0.65 to -0.06); 2) cardiovascular dimensions (resting diastolic blood pressure, 11 studies, 419 participants: MD 2.32 mm Hg, 95% CI 0.59 to 4.05; resting systolic blood pressure, 9 studies, 347 participants: MD 6.08 mm Hg, 95% CI 2.15 to 10.12; heart rate, 11 studies, 229 participants: MD 6 bpm, 95% CI 10 to 2); 3) some nutritional parameters (albumin, 3 studies, 111 participants: MD -2.28 g/L, 95% CI -4.25 to -0.32; pre-albumin, 3 studies, 111 participants: MD - 44.02 mg/L, 95% CI -71.52 to -16.53; energy intake, 4 studies, 97 participants: SMD -0.47, 95% CI -0.88 to -0.05); and 4) health-related quality of life. Results also showed how exercise should be designed in order to optimise the effect. Other outcomes had insufficient evidence.

AUTHORS' CONCLUSIONS

There is evidence for significant beneficial effects of regular exercise on physical fitness, walking capacity, cardiovascular dimensions (e.g. blood pressure and heart rate), health-related quality of life and some nutritional parameters in adults with CKD. Other outcomes had insufficient evidence due to the lack of data from RCTs. The design of the exercise intervention causes difference in effect size and should be considered when prescribing exercise with the aim of affecting a certain outcome. Future RCTs should focus more on the effects of resistance training interventions or mixed cardiovascular- and resistance training as these exercise types have not been studied as much as cardiovascular exercise.

Current best evidence recommendations on measurement and interpretation of physical function in patients with chronic kidney disease

Chronic kidney disease (CKD) is becoming a serious health problem throughout the world and is one of the most potent known risk factors for cardiovascular disease. Deterioration of physical function is accelerated in patients with CKD to levels that significantly impact on clinically and patient-important outcomes such as morbidity, employment, quality of life and, ultimately, survival. However, meaningful interpretation of the existing physical function-related literature in adult patients with CKD is hindered, possibly due to inconsistent choice of methodology, assessment tools and reporting of data. The current comprehensive review of the literature aims to provide the theoretical rationale and framework for physical function assessment and to identify the prevailing approaches to (i) the characterization (classification and terminology), (ii) interpretation, and (iii) reporting of physical function assessment in people with CKD. Comprehensive assessment of physical function can provide important information about the presence of 'physiological impairment' at a body systems level (exercise tolerance under well controlled, laboratory-based procedures), 'functional limitations' (physical performance during tasks imitating usual daily, personal or occupational tasks) and 'functional disability' (via self-reported physical functioning in the context of a socio-cultural environment). The selection of physical function assessment tools should be guided by the primary purpose of the assessment (e.g. research or routine clinical monitoring), by the overall scientific 'soundness' of the chosen tool (e.g. validity, utility, reproducibility, responsiveness characteristics) and by operational factors (e.g. patient collaboration, cost, personnel expertise). Recommendations for tests, methods and protocols are therefore presented, for the assessment of cardiorespiratory and muscular fitness, physical performance and self-reported physical functioning. These recommendations are based on synthesis of available information as derived from controlled exercise training interventions in adult patients with CKD. Special considerations for physical function assessment and suggestions for future research are also addressed. Such an information synthesis might promote greater standardization of the physical function assessment of patients with CKD in routine clinical care or research settings. This would potentially lead to generation of adequate scientific decision-making criteria to help researchers and healthcare providers in selecting the most appropriate measures according to the physical function areas assessed, and to accurately and meaningfully characterize and compare patients' responses to therapeutic interventions.

Development and psychometric evaluation of the Dialysis patient-perceived Exercise Benefits and Barriers Scale

BACKGROUND

Perceptions of exercise benefits and barriers affect exercise behavior. Because of the clinical course and treatment, dialysis patients differ from the general population in their perceptions of exercise benefits and barriers, especially the latter. At present, no valid instruments for assessing perceived exercise benefits and barriers in dialysis patients are available.

OBJECTIVES

Our goal was to develop and test the psychometric properties of the Dialysis patient-perceived Exercise Benefits and Barriers Scale (DPEBBS).

METHODS

A literature review and two focus groups were conducted to generate the initial item pool. An expert panel examined the content validity. Then, 269 Chinese hemodialysis patients were recruited by convenience sampling. Exploratory and confirmatory factor analyses were used to test construct validity. Finally, internal consistency and test-retest reliability were assessed.

RESULTS

The expert panel determined that the content validity index was satisfactory. The final 24-item scale consisted of six factors explaining 57% of the total variance in the data. Confirmative factor analysis supported the six-factor structure and a higher-order model. Cronbach's alpha was 0.87 for the total scale, and 0.84 for test-retest reliability.

CONCLUSION

The DPEBBS was a valid and reliable instrument for evaluating dialysis patients' perceived benefits and barriers to exercise. The application value of this scale remains to be investigated by increasing the sample size and evaluating patients undergoing different dialysis modalities and coming from different regions and cultural backgrounds.

Quality of life comparison between corticosteroid- and-mycofenolate mofetil and corticosteroid- and-oral cyclophosphamide in the treatment of severe lupus nephritis

There is accumulating evidence that mycophenolate mofetil (MMF), when combined with corticosteroid, is an effective induction treatment for severe proliferative lupus nephritis and is associated with fewer adverse effects compared to cyclophosphamide (CTX), but the quality of life (QOL) associated with these regimens as perceived by the patient has not been compared. This study included patients who had experienced both treatment regimens, for distinct episodes of diffuse proliferative lupus nephritis. QOL parameters during the first six months of each treatment were assessed through SF36 and WHOQOL questionnaires. Twelve patients and 24 episodes of severe lupus nephritis were studied. CTX-treated and MMF-treated episodes showed comparable baseline characteristics and response rate, with complete remission occurring in 83.3%. MMF treatment was associated with higher numerical scores for all domains across both QOL instruments than CTX. MMF treatment was associated with significantly less fatigue, less impediment of physical and social functioning, and better psychological well being compared to CTX. When each patient served as her/his own control, most patients ascribed higher QOL domain scores to the MMF-treated episode. Seventy-five percent of patients found MMF treatment more acceptable and preferred when compared with CTX, and the complications that most concerned them included Cushingoid features, alopecia, menstrual disturbance and infections. These data showed that MMF-based induction immunosuppression for severe lupus nephritis was associated with better QOL than CTX as perceived by patients, which was most likely attributed to the reduced side-effects during MMF treatment.

Physical activity patterns in chronic hemodialysis patients: comparison of dialysis and nondialysis days

OBJECTIVE

To determine physical activity patterns in chronic hemodialysis patients with a specific emphasis on the difference between dialysis and nondialysis days. Design A cross-sectional single-center study.

SETTING

Vanderbilt University Outpatient Dialysis Unit.

PATIENTS

Twenty current chronic hemodialysis patients: 10 male, 10 female; 15 black, 5 white; mean age, 50.1 +/- 9.9 years; height, 164.5 +/- 10.9 cm; weight, 82.5 +/- 15.4 kg; length on dialysis, 57.3 +/- 45.3 months.

METHODS

Minute-by-minute physical activity was assessed over a 7-day period using a triaxial accelerometer, which consists of raw numbers or counts calculated by the 3 axes of the accelerometer (PA counts). PA counts were extrapolated on a daily and hourly basis. Physical functioning tests included: sit-to-stand, 6-minute walk, and 1-repetition maximal leg press exercise. Laboratory values for serum concentrations of albumin, prealbumin, C-reactive protein, and cholesterol were also collected.

MAIN OUTCOME MEASURE

PA counts.

RESULTS

Total PA counts were significantly lower on dialysis days when compared with nondialysis days (128,279 +/- 74,009 versus 168,744 +/- 95,168, respectively, P = .025). The average PA counts during the 4-hour dialysis time period were significantly lower on dialysis days when compared with nondialysis days (3,086 +/- 3,749 versus 11,070 +/- 7,695, respectively, P = .001). At postdialysis hours 1 and 2, PA counts on dialysis days were significantly higher than on nondialysis days (11,410 +/- 5,340 versus 9,082 +/- 6,646, P = .008, and 14,048 +/- 9,728 versus 8,662 +/- 6,433, P = .016, respectively). By postdialysis hour 4, PA counts on dialysis days had significantly decreased when compared with nondialysis days (6,068 +/- 6,268 versus 10,512 +/- 7,420 PA counts, P = .01, respectively). From postdialysis hours 5 to 20, there was no significant difference in PA counts between dialysis and nondialysis days.

CONCLUSION

This study shows that physical activity is lower on dialysis days when compared with nondialysis days, and this decrease is caused by the lack of activity during the 4-hour hemodialysis procedure. New behavior modification strategies involving physical activity, both during hemodialysis and on nondialysis days, must be examined in this patient population.

Health-related quality of life predicts outcomes but is not affected by peritoneal clearance: The ADEMEX trial

BACKGROUND

We hypothesized that increasing small solute clearance in peritoneal dialysis (PD) would lead to improvements in patient health-related quality of life (HRQOL).

METHODS

Patients were randomized to a control group [standard 4 x 2 L continuous ambulatory peritoneal dialysis (CAPD)] and an intervention group (CAPD with a target creatinine clearance >/=60 L/week/1.73 m(2)). The Kidney Disease Quality of Life Short Form was obtained at baseline and at 6, 12, and 24 months. Physical (PCS), mental (MCS), and kidney disease component summary (KDCS) scores were computed.

RESULTS

The two groups were comparable at baseline with respect to HRQOL. Baseline variables highly predictive of better QOL included absence of diabetes, younger age, higher starting GFR, and serum albumin. Baseline values of QOL were highly predictive of survival and hospitalizations. An unadjusted comparison revealed that patients in the intervention group had significantly higher PCS and KDCS scores at six months. However, there were no significant differences between the intervention and control patients at 12 or 24 months. When similar analyses were carried out adjusting for different patterns of patient dropout, there were no significant differences between the two groups at any time point in terms of PCS, MCS, and KDCS scores.

CONCLUSION

We found no evidence of a long-term benefit in HRQOL of CAPD patients by increasing peritoneal small-solute clearances when HRQOL parameters were adjusted for patient dropout. Measures of HRQOL have a significant predictive value for patient survival and hospitalizations.

Effect of exercise training on interdialytic ambulatory and treatment-related blood pressure in hemodialysis patients

BACKGROUND

Exercise training improves blood pressure (BP) in the general population, but prior studies in hemodialysis (HD) patients only used pill counts or treatment-related BPs. We evaluated the effect of 3 to 6 months of intradialytic exercise training on ambulatory blood pressure (ABP) and treatment-related pre- and postdialysis BP.

PATIENTS AND METHODS

Nineteen chronic HD patients trained with an exercise bicycle for 30 to 60 min in the first 1 to 2 hr of each of thrice weekly HD. Interdialytic 44-hr ABP was performed a week before training began and repeated at 3 and 6 months. Pre- and post-HD systolic and diastolic BP and pre- and post-HD weight were recorded for 2 months prior to training, throughout the training, and, if available, for the 2 months after training ended. BP medications were recorded throughout. Body composition by bioimpedance, and norepinephrine and epinephrine levels by RIA were done at 0, 3, and 6 months.

RESULTS

Thirteen subjects who completed at least 3 months of training exercised 90% of HD sessions for 56 min +/- 23 SD each. Systolic and diastolic 44-hr interdialytic ABP fell during training (systolic 138.4 mmHg +/- 19.6 vs. 125.7 mmHg +/- 20.0 vs. 125.9 mmHg +/- 22.9; diastolic 83.2 mmHg +/- 10.2 vs. 74.7 mmHg +/- 9.0 vs. 73.9 mmHg +/- 11.8 at 0, 3, and 6 months; p < .05 ANOVA). Norepinephrine and epinephrine levels did not independently predict systolic BP. Pre-HD systolic BP was stable during the pretraining period, fell significantly during the training period (p < .03), and returned toward preexercise levels during the posttraining period (p < .001). Pre- or postweight, erythropoietin dose, total body water, and number of BP meds were unchanged.

CONCLUSION

Exercise training during HD significantly improves both interdialytic ABP and treatment-related BP.

Motor performance, exercise tolerance, and health-related quality of life in children on dialysis

In contrast to the adult population, little is known regarding health-related quality of life and exercise tolerance in children with end-stage renal disease (ESRD) undergoing chronic intermittent hemodialysis. We designed a pilot study to investigate whether research into this area is indicated. The aim of this study was to describe the motor skills, exercise tolerance, and health-related quality of life in children with ESRD. The study population consisted of ten hemodialysis patients (aged 7-16 years). In eight children motor proficiency according to Bruininks-Oseretsky was determined. In all ten children a progressive exercise test on a treadmill was performed. The results were compared with an age-matched healthy reference group. Nine children filled in the TNO-AZL Child Quality of Life (TACQOL) scoring list. One child had a markedly reduced fine motor skills capacity; another five children scored < or = -2 SD compared with healthy children in gross motor skills. Seven children showed a diminished VO(2)max (per kilogram body weight); six of these are physically inactive. Four of these seven children did not sustain the maximum workload. The self-assessed physical and mental health of children on dialysis seems comparable to the general population. We found no correlation between exercise performance or motor skills and hemoglobin levels, Kt/V, and time on dialysis. In conclusion, in this study most children had a reduced exercise tolerance and gross motor skills. There was no difference in fine motor skills. Pediatric dialysis patients report a good health-related quality of life.

Renal rehabilitation and improved patient outcomes in Texas dialysis facilities

BACKGROUND

Because a cure is not a reasonable goal for patients with end-stage renal disease (ESRD), optimal physical and mental health functioning are primary objectives of care and major determinants of health-related quality of life, morbidity, and mortality. This cross-sectional study used facility-level survey data to test the hypothesis that dialysis unit rehabilitation activities are associated with higher patient functional status.

METHODS

Data were collected from 169 dialysis facilities in the ESRD Network of Texas (Network 14), including facility characteristics, facility-level patient demographic and clinical characteristics, and facility rehabilitation activities measured by the Life Options Unit Self-Assessment Tool (USAT). Facility-level data on patient functioning and well-being measured by the Medical Outcomes Study 36-Item Short-Form Health Survey were obtained from all 86 of the respondent facilities that collected it.

RESULTS

Most participating facilities reported performing rehabilitation activities in all five categories (encouragement, education, exercise, employment, and evaluation). The median number reported was 32 of a possible 100 activities. Exercise interventions were the least often implemented activities. Linear multiple regression showed that facility rehabilitation activity scores measured by the USAT were associated with higher facility mean Mental Component Scale (MCS) scores, controlling for facility characteristics (size, profit status), facility-level patient demographic characteristics (diabetes, race, sex, age), and facility-level patient laboratory variables: urea reduction ratio and hemoglobin and serum albumin levels.

CONCLUSION

Because MCS scores have been shown in other studies to be inversely related to morbidity and mortality, this finding suggests that the introduction of rehabilitation interventions into the dialysis care regimen may prove beneficial.

Assessing the efficacy of exercise training in patients with chronic disease

PURPOSE

The purpose of this study was to evaluate the meaningfulness of exercise training responses in patients with end stage renal disease (ESRD).

METHODS

Eighteen ESRD patients [(mean +/- SD); 54.3 +/- 17.1 yr] completed a training regime progressing to accumulate 40 min of stationary cycling, three times per week for 6 months. .VO(2peak) determined via incremental cycle ergometer protocol, and .VO(2) kinetics determined from a transition from unloaded pedalling to an exercise intensity corresponding to 90% of VT, were assessed at baseline and at 3 and 6 months of training.

RESULTS

Repeated measures analysis of variance revealed significant changes (P < 0.05) on the time factor for .VO(2peak), VO(2)-V(T), and .VO(2) kinetics. Post hoc analysis revealed that .VO(2peak) and .VO(2) kinetics significantly (P < 0.05) improved at 3 months of training with no further improvements thereafter. Analysis of individual subject response data revealed that after 3 months of training, 61% of the patients improved .VO(2peak) by greater than the standard error of measurement (SEM = 0.07 L.min(-1)). At 6 months of training, approximately 89% of the patients improved by more than the SEM .VO(2) kinetics improved by more than the SEM (12.3 s) at 3 months of training in approximately 55% of the patients, with no increase in the number of patients exhibiting faster time constants after 6 months of training.

CONCLUSION

Although conventional statistical analyses indicate that exercise training favorably alters .VO(2peak) and oxygen uptake kinetics of patients with ESRD, it is apparent that considerable interindividual variability exists in the response to training. Consideration of the SEM data underscores the heterogeneity of adaptive response in this patient group and may be valuable in assessing the efficacy of therapeutic exercise rehabilitation.

Effects of regular exercise on anxiety, depression, and quality of life in maintenance hemodialysis patients

BACKGROUND

Psychological problems such as depression and anxiety are common in hemodialysis patients. In several studies, exercise programs were effective in relieving depression or anxiety in these patients, although not all agree.

PURPOSE

In this study, we evaluated the effects of an exercise program on exercise capacity, anxiety, depression and quality of life in maintenance hemodialysis patients.

METHODS

Twenty hemodialysis patients were enrolled in the study. Six patients were later excluded; two due to anemia, one due to nausea with vomiting during exercise, one due to a neurologic problem, and the other two due to noncompliance. Thus, fourteen patients, 3 men and 11 women, aged 42 +/- 10 years, completed the study. The exercise program composed of bicycle ergometer, treadmill or upper limb ergometer, 60 min per session, 3 times per week, for 12 weeks. At the beginning and the end of the exercise program, the exercise capacity was determined by measuring the maximal oxygen consumption and exercise duration. In addition, psychological tests for the assessment of depression, anxiety and quality of life were performed.

RESULTS

Maximal oxygen consumption was increased from 26.3 +/- 4.6 mL/kg/min to 29.8 +/- 4.9 mL/kg/min (p = 0.013). Exercise duration was 483 +/- 138 s at the start. At the end of the exercise program it was increased to 607 +/-119s (p = 0.002). The score of anxiety was significantly improved from 47.9 +/- 5.9 to 42.8 +/- 6.3 after exercise (p = 0.004). Though it did not reach statistical significance there was a trend of improvement in depression (from 44.8 +/- 8.4 to 39.7 +/- 6.4, p = 0.073). The score of quality of life also showed a significant improvement (from 124.5 +/- 16.5 to 133.6 +/- 19.3, p = 0.031).

CONCLUSION

The results of this study indicate that an appropriate application of exercise program would improve the psychological status in long-term maintenance hemodialysis patients.

Effects of exercise training on aerobic and functional capacity of end-stage renal disease patients

The aim was to assess the effects of exercise training on aerobic and fuctional capacity of patients with end-stage renal disease (ESRD). Patients completed an incremental exercise test on a cycle ergometer to determine VO2 peak and VO2 at ventilatory threshold (VT; V-slope). On a separate day they performed two constant load exercise tests on a cycle ergometer at 90% of VT and at a workload of 33 W, to determine VO2 kinetics. Functional capacity was assessed using measurements of sit-to-stands (STS-5, STS-60) and a walk test. Dialysis patients were randomly allocated to an exercise (ET: n = 18, age = 57.3 years) or control (C: n = 15, age = 50.5 - 5 years) group. The ET group participated in an exercise training programme involving cycling for 3 months. Repeated measures ANOVA revealed significant time by group interactions (P < 0.05) following training for VO2 peak (ET: 17 +/- 6.1 versus 19.9 +/- 6-3, C: 19.5 +/- 4.7 versus 188 +/- 4.9 ml kg min(-1)) and VO2-VT (ET: 10.7 +/- 3.5 versus 11.8 +/- 3.3, C:12.9 +/- 3.2 versus 119 +/- 3.5 ml kg min(-10). VO2 kinetics remained unchanged in both groups at 90% -VT, but a trend (P = 0.059) towards faster kinetics at the 33 W was observed (ET: 49.6 +/- 19.5 versus 37.8 +/- 12.7, C: 42.8 +/- 13 versus 49.4 +/- 20.2 s). Significant time by group interactions (P < 0.05) were also observed for STS-5 (ET: 14.7 +/- 6.2 versus 11.0 +/- 3.3, C: 12.8 +/- 4.4 versus 12.7 +/- 4.8 s) and STS-60 measurements (ET: 21.2 + 7.2 versus 26.9 +/- 6.2, C: 23.7 +/- 6.8 versus 24.1 +/- 7.2). Three months of exercise rehabilitation significantly improves peak exercise capacity of patients with ESRD. Measurements of VO2 kinetics and functional capacity suggest that longer time might be needed to induce peripheral adaptations.

Development of subscales from the symptoms/problems and effects of kidney disease scales of the kidney disease quality of life instrument

BACKGROUND

The Kidney Disease Quality of Life Instrument (KDQOL) was developed to provide clinicians with a comprehensive assessment of the important domains of health-related quality of life (HRQOL) for patients with end-stage renal disease who are undergoing hemodialysis.

OBJECTIVE

The purpose of this study was to develop subscales from the 55 items comprising the Symptoms/Problems and Effects of Kidney Disease scales of the KDQOL and to measure the internal consistency reliability of these subscales.

METHODS

The 55 items from the Symptoms/Problems and Effects of Kidney Disease scales were arranged into substantively meaningful clusters using an affinity mapping procedure. The resulting subscales were assessed for internal consistency reliability using data from a sample of 165 individuals with kidney disease who had completed the KDQOL.

RESULTS

Eleven multi-item subscales were identified: pain, psychological dependency, cognitive functioning, social functioning, dialysis-related symptoms, cardiopulmonary symptoms, sleep, energy, cramps, diet, and appetite. Four items (clotting or other problems with access site, high blood pressure, numbness in hands or feet, and blurred vision) were not included in any of these subscales. Internal consistency reliability estimates for the 11 subscales ranged from 0.66 to 0.92. These subscales correlated with the scales from the 36-Item Short-Form Health Survey as hypothesized (ie, corresponding pain, energy, and social functioning scales had the highest correlations). In addition, several subscales were significantly associated, as hypothesized, with other variables such as the number of disability days.

CONCLUSIONS

The results of this study further support the reliability and validity of the KDQOL. The 11 subscales identified yield more detailed information on the HRQOL of patients with kidney disease and provide a basis for specific improvements in the quality of care delivered to these patients.