Kidney transplantation: a systematic review of interventional and observational studies of physical activity on intermediate outcomes

Factors Associated With Physical Inactivity of Recipients of a Kidney Transplant: Results From the ADHERE BRAZIL Multicenter Study

OBJECTIVE

Physical activity is recommended for recipients of a kidney transplant. However, ADHERE BRAZIL study found a high prevalence (69%) of physical inactivity in Brazilian recipients of a kidney transplant. To tackle this behavior, a broad analysis of barriers is needed. This study aimed to identify factors (patient and transplant center levels) associated with physical inactivity among recipients of a kidney transplant.

METHODS

This was a subproject of the ADHERE BRAZIL study, a cross-sectional, multicenter study of 1105 recipients of a kidney transplant from 20 kidney transplant centers. Using a multistage sampling method, patients were proportionally and randomly selected. Applying the Brief Physical Activity Assessment questionnaire, patients were classified as physically active (≥150 min/wk) or physically inactive (<150 min/wk). On the basis of an ecological model, 34 factors associated with physical inactivity were analyzed by sequential logistic regression.

RESULTS

At the patient level, physical inactivity was associated with smoking (odds ratio = 2.43; 95% CI = 0.97-6.06), obesity (odds ratio = 1.79; 95% CI = 1.26-2.55), peripheral vascular disease (odds ratio = 3.18; 95% CI = 1.20-8.42), >3 posttransplant hospitalizations (odds ratio = 1.58; 95% CI = 1.17-2.13), family income of >1 reference salary ($248.28 per month; odds ratio = 0.66; 95% CI = 0.48-0.90), and student status (odds ratio = 0.58; 95% CI = 0.37-0.92). At the center level, the correlates were having exercise physiologists in the clinical team (odds ratio = 0.54; 95% CI = 0.46-0.64) and being monitored in a teaching hospital (undergraduate students) (odds ratio = 1.47; 95% CI = 1.01-2.13).

CONCLUSIONS

This study identified factors associated with physical inactivity after kidney transplantation that may guide future multilevel behavioral change interventions for physical activity.

IMPACT

In a multicenter sample of recipients of a kidney transplant with a prevalence of physical inactivity of 69%, we found associations between this behavior and patient- and center-level factors. At the patient level, the chance of physical inactivity was positively associated with smoking, obesity, and patient morbidity (peripheral vascular disease and hospitalization events after kidney transplantation). Conversely, a high family income and a student status negatively correlated with physical inactivity. At the center level, the presence of a dedicated professional to motivate physical activity resulted in a reduced chance of physical inactivity. A broad knowledge of barriers associated with physical inactivity can allow us to identify patients at a high risk of not adhering to the recommended levels of physical activity.

The activity advantage: Objective measurement of preoperative activity is associated with postoperative recovery and outcomes in patients undergoing surgery with gynecologic oncologists

OBJECTIVE

To examine the association between objectively-measured preoperative physical activity with postoperative outcomes and recovery milestones in patients undergoing gynecologic oncology surgeries.

METHODS

Prospective cohort study of patients undergoing surgery with gynecologic oncologists who wore wearable actigraphy rings before and after surgery from 03/2021-11/2023. Exposures encompassed preoperative activity intensity (moderate- and vigorous-intensity metabolic equivalent of task-minutes [MAVI MET-mins] over seven days) and level (average daily steps over seven days). Intensity was categorized as <500, 500-1000, and >1000 MAVI MET-mins; level categorized as <8000 and ≥8000 steps/day. Primary outcome was 30-day complications. Secondary outcomes included reaching postoperative goal (≥70% of recommended preoperative intensity and level thresholds) and return to baseline (≥70% of individual preoperative intensity and level).

RESULTS

Among 96 enrolled, 87 met inclusion criteria, which constituted 39% (n = 34) with <500 MET-mins and 56.3% (n = 49) with <8000 steps preoperatively. Those with <500 MET-mins and <8000 steps had higher ECOG scores (p = 0.042 & 0.037) and BMI (p = 0.049 & 0.002) vs those with higher activity; all other perioperative characteristics were similar between groups. Overall, 29.9% experienced a 30-day complication, 29.9% reached postoperative goal, and 64.4% returned to baseline. On multivariable models, higher activity was associated with lower odds of complications: 500-1000 MET-mins (OR = 0.26,95%CI = 0.07-0.92) and >1000 MET-mins (OR = 0.25,95%CI = 0.07-0.94) vs <500 MET-mins; ≥8000 steps (OR = 0.25,95%CI = 0.08-0.73) vs <8000 steps. Higher preoperative activity was associated fewer days to reach postoperative goal.

CONCLUSION

Patients with high preoperative activity are associated with fewer postoperative complications and faster attainment of recovery milestones. Physical activity may be considered a modifiable risk factor for adverse postoperative outcomes.

Barriers and Facilitators to Exercise in Older Adults Awaiting Kidney Transplantation and Their Care Partners

Rationale & Objective

Despite guidelines calling to improve physical activity in older adults, and evidence suggesting that prekidney transplant physical function is highly associated with posttransplant outcomes, only a small percentage of older patients treated with dialysis are engaged in structured exercise. We sought to elucidate barriers and facilitators of exercise among older adults treated with dialysis awaiting transplant and their care partners.

Study Design

Individual, in-depth, cognitive interviews were conducted separately for patients and care partners through secure web-conferencing.

Setting & Participants

Twenty-three patients (≥50 years of age, treated with dialysis from the University of San Francisco kidney transplantation clinic, with a short physical performance battery of ≤10) and their care partners.

Analytical Approach

All audio interviews were transcribed verbatim. Three investigators independently coded data and performed qualitative thematic content. The interview guide was updated iteratively based on the Capability Opportunity Motivation Behavior model.

Results

Patients' median age was 60 years (57 ± 63.5) and care partners' median ages was 57 years (49.5 ± 65.5). Thirty-nine percent of patients and 78% of care partners were female, 39% of patients and 30% of care partners self-identified as African American, and 47% of dyads were spouse or partner relationships. Major themes for barriers to pretransplant exercise included lack of understanding of an appropriate regimen, physical impairments, dialysis schedules, and safety concerns. Major facilitators included having individualized or structured exercise programs, increasing social support for patients and care partners, and motivation to regain independence or functionality or to promote successful transplantation.

Limitations

Participants geographically limited to Northern California.

Conclusions

Although patients and care partners report numerous barriers to pretransplant exercise and activity, they also reported many facilitators. An individualized, structured, home-based exercise program could circumvent many of the reported barriers and allow older patients to improve pretransplant physical function.

Disseminating education to solid organ transplant recipients to promote engagement in physical activity

Objective

To evaluate the dissemination of education through a workshop to promote engagement in physical activity (PA) among solid organ transplant (SOT) recipients.

Methods

The in-person workshop consisted of expert-led lectures on topics related to physical activity (day 1) and sports and fitness training with volunteer coaches (day 2). There were separate streams for children/adolescents and adults. RE-AIM (Reach, Efficacy, Adoption, Implementation, and Maintenance) framework was used to evaluate the impact of the workshop. Presenters and participants completed evaluations of the workshop using a 5-point Likert scale. A subgroup of adults completed a self-reported PA questionnaire at baseline and 4-weeks after the workshop.

Results

103 individuals (71 SOT recipients, 32 caregivers) attended the workshop (ages 4 to 71+ years). Sessions were highly rated (median = 5) for both quality and content on both days. There was no significant change (p = 0.16) in PA. However, 56% of SOT recipients reported changing their level of PA.

Conclusion

An educational-workshop with hands-on training was an efficient and well-received method for disseminating awareness about the benefits of PA in SOT recipients.

Innovation

Dissemination of evidence-based knowledge through a novel educational-workshop in a real-world setting has the potential to inform the decisions about PA behavior among SOT recipients.

Rethinking Rehabilitation: A REVIEW OF PATIENT POPULATIONS WHO CAN BENEFIT FROM CARDIAC REHABILITATION

Although cardiac rehabilitation (CR) is safe and highly effective for individuals with various cardiovascular health conditions, to date there are only seven diagnoses or procedures identified by the Centers for Medicare & Medicaid Services that qualify for referral. When considering the growing number of individuals with cardiovascular disease (CVD), or other health conditions that increase the risk for CVD, it is important to determine the extent for which CR could benefit these populations. Furthermore, there are some patients who may currently be eligible for CR (spontaneous coronary artery dissection, left ventricular assistant device) but make up a relatively small proportion of the populations that are regularly attending and participating. Thus, these patient populations and special considerations for exercise might be less familiar to professionals who are supervising their programs. The purpose of this review is to summarize the current literature surrounding exercise testing and programming among four specific patient populations that either do not currently qualify for (chronic and end-stage renal disease, breast cancer survivor) or who are eligible but less commonly seen in CR (sudden coronary artery dissection, left ventricular assist device). While current evidence suggests that individuals with these health conditions can safely participate in and may benefit from supervised exercise programming, there is an immediate need for high-quality, multisite clinical trials to develop more specific exercise recommendations and support the inclusion of these populations in future CR programs.

Physical Inactivity: A Modifiable Risk Factor for Morbidity and Mortality in Kidney Transplantation

In patients with chronic kidney disease, sedentary behavior is widely recognized as a significant risk factor for cardiovascular disease, diabetes, obesity, osteoporosis, cancer, and depression. Nevertheless, the real impact of physical inactivity on the health of kidney transplant (KT) recipients remains uncertain. Over the last decade, there has been a renewed interest in exploring the effects of regular physical exercise on transplant-related outcomes. There is now mounting evidence that physical activity may reduce the burden of cardiovascular risk factors, preserve allograft function, minimize immunosuppression requirement, and ameliorate the quality of life of KT recipients. Many positive feedbacks can be detected in the early stages of the interventions and with a minimal exercise load. Despite these encouraging results, the perceived role of physical activity in the management of KT candidates and recipients is often underrated. The majority of trials on exercise training are small, relatively short, and focused on surrogate outcomes. While waiting for larger studies with longer follow-up, these statistical limitations should not discourage patients and doctors from initiating exercise and progressively increasing intensity and duration. This narrative review summarizes current knowledge about the deleterious effects of physical inactivity after KT. The benefits of regular physical exercise are also outlined.

Obesity and Post-Transplant Diabetes Mellitus in Kidney Transplantation

Worldwide, the prevalence obesity, diabetes, and chronic kidney disease is increasing apace. The relationship between obesity and chronic kidney disease is multidimensional, especially when diabetes is also considered. The optimal treatment of patients with chronic kidney disease includes the need to consider weight loss as part of the treatment. The exact relationship between obesity and kidney function before and after transplantation is not as clear as previously imagined. Historically, patients with obesity had worse outcomes following kidney transplantation and weight loss before surgery was encouraged. However, recent studies have found less of a correlation between obesity and transplant outcomes. Transplantation itself is also a risk factor for developing diabetes, a condition known as post-transplant diabetes mellitus, and is related to the use of immunosuppressive medications and weight gain following transplantation. Newer classes of anti-diabetic medications, namely SGLT-2 inhibitors and GLP-1 agonists, are increasingly being recognized, not only for their ability to control diabetes, but also for their cardio and renoprotective effects. This article reviews the current state of knowledge on the management of obesity and post-transplant diabetes mellitus for kidney transplant patients.

The FRAILMar Study Protocol: Frailty in Patients With Advanced Chronic Kidney Disease Awaiting Kidney Transplantation. A Randomized Clinical Trial of Multimodal Prehabilitation

Introduction: Frailty is very frequent among patients with chronic kidney disease (CKD) who are awaiting deceased donor kidney transplantation (KT), and transplant outcomes are worsened in those frail recipients. Frailty and poor fitness powerfully predict mortality, kidney graft survival, and healthcare utilization after KT. Intervention is essential to improve survival and quality of life for frail CKD patients, regardless of their age. Studies of post-transplant physical therapy intervention have been met with limited success, in large part due to high dropout rates. A pre-transplant clinical framework for multimodal prehabilitation interventions including physical therapy, nutritional measures, and psychological support scheduled during the KT waiting list period may improve patient retention and compliance, better mitigate the effects of frailty and poor fitness after KT, and improve main outcomes in frail CKD patients.

Main Objective: To study the effectiveness, feasibility, and safety of multimodal prehabilitation (exercise, nutritional plans, psychological advice) in KT candidates.

Methods: Randomized controlled clinical trial in 38 frail and 76 non-frail KT candidates. The prehabilitation program will consist of physical exercise (24 sessions, 8 weeks), nutritional supplementation, and psychological advice. The primary endpoint will be a composite achievement of clinical and functional main outcomes in frail and non-frail KT candidates at 90 days post-transplantation. Secondary outcomes include changes in exercise capacity, physical activity, gait speed, respiratory and peripheral muscle strength, muscle size, body composition, performance in activities of daily living (basic and instrumental), anxiety and depression symptoms, and health-related quality of life. Feasibility of the intervention will be also analyzed.

Expected Results: Multimodal prehabilitation is a feasible and effective intervention to decrease bad outcomes at 90 days post-KT by 25 and 12.5% in frail and non-frail patients, respectively.

Clinical Trial Registration:clinicaltrials.gov (NCT04701398), date: 2021, January 8th (Protocol version: Frailmar_vers2).

The effects of exercise training in adult solid organ transplant recipients: A systematic review and meta-analysis

Reduced exercise capacity can predispose solid organ transplant (SOT) recipients to higher risk of diabetes, cardiovascular complications, and mortality and impact their quality of life. This systematic review and meta-analysis investigated the effects of exercise training (versus no training) in adult SOT recipients. We conducted an electronic search of randomized controlled trials reporting on exercise interventions in SOT recipients. Primary outcomes were exercise capacity, quadriceps muscle strength, and health-related quality of life (HRQoL). Twenty-nine articles met the inclusion criteria. In 24 studies, there were either high risk of bias or some concerns about the potential risk of bias. There was an increase in exercise capacity (VO₂ peak) (SMD: 0.40; 95%CI 0.22-0.57; P = 0.0) and quadriceps muscle strength (SMD: 0.38; 95%CI 0.16-0.60; P = 0.001) in the exercise vs control groups. There were also improvements in several domains of the SF-36. Diastolic blood pressure improved in the exercise group compared to controls (SMD: -0.22; 95%CI -0.41-0.03; P = 0.02). Despite the considerable variation in exercise training characteristics and high risk of bias in the included studies, exercise training improved maximal exercise capacity, quadriceps muscle strength, HRQoL, and diastolic blood pressure and should be an essential part of the post-transplant care.

Physical activity and risk of cardiovascular events and all-cause mortality among kidney transplant recipients

BACKGROUND

Insufficient physical activity (PA) may increase the risk of all-cause mortality and cardiovascular disease (CVD) morbidity and mortality among kidney transplant recipients (KTRs), but limited research is available. We examine the relationship between PA and the development of CVD events, CVD death and all-cause mortality among KTRs.

METHODS

A total of 3050 KTRs enrolled in an international homocysteine-lowering randomized controlled trial were examined (38% female; mean age 51.8 ± 9.4 years; 75% white; 20% with prevalent CVD). PA was measured at baseline using a modified Yale Physical Activity Survey, divided into tertiles (T1, T2 and T3) from lowest to highest PA. Kaplan-Meier survival curves were used to graph the risk of events; Cox proportional hazards regression models examined the association of baseline PA levels with CVD events (e.g. stroke, myocardial infarction), CVD mortality and all-cause mortality over time.

RESULTS

Participants were followed up to 2500 days (mean 3.7 ± 1.6 years). The cohort experienced 426 CVD events and 357 deaths. Fully adjusted models revealed that, compared to the lowest tertile of PA, the highest tertile experienced a significantly lower risk of CVD events {hazard ratio [HR] 0.76 [95% confidence interval (CI) 0.59-0.98]}, CVD mortality [HR 0.58 (95% CI 0.35-0.96)] and all-cause mortality [HR 0.76 (95% CI 0.59-0.98)]. Results were similar in unadjusted models.

CONCLUSIONS

PA was associated with a reduced risk of CVD events and all-cause mortality among KTRs. These observed associations in a large, international sample, even when controlling for traditional CVD risk factors, indicate the potential importance of PA in reducing CVD and death among KTRs.

Malnutrition according to GLIM criteria in stable renal transplant recipients: Reduced muscle mass as predominant phenotypic criterion

BACKGROUND & AIMS

Malnutrition has a negative impact on quality of life and survival in renal transplant recipients (RTR). Therefore, malnutrition detection is important in RTR, but this may be hampered by concomitant presence of weight gain and overweight. Recently, the Global Leadership Initiative on Malnutrition (GLIM) developed a set of diagnostic criteria for malnutrition. We aimed to assess the prevalence of malnutrition according to the GLIM criteria and the distribution of phenotypic criteria in RTR. Additionally, we examined the potential value of 24-h urinary creatinine excretion rate (CER) as alternative measure for the criterion reduced muscle mass.

METHODS

We used data from stable outpatient RTR included in the TransplantLines Cohort and Biobank Study (NCT02811835). Presence of weight loss and reduced intake or assimilation were derived from Patient-Generated Subjective Global Assessment (PG-SGA) item scores. Reduced muscle mass was assessed by multi-frequency bio-electrical impedance analysis (MF-BIA) and defined as an appendicular skeletal muscle mass index (ASMI) < 7 kg/m² for men and <5.5 kg/m² for women, and in additional analysis defined as creatinine-height index (CHI, based on 24 h urine CER) < 80%. Inflammation was present if C-reactive protein (CRP) was >5 mg/L. Malnutrition was defined as presence of at least one phenotypic (weight loss and/or low BMI and/or reduced muscle mass) and one etiologic criterion (reduced intake/assimilation and/or disease burden/inflammation).

RESULTS

We included 599 RTR (55 ± 13 years old, 62% male, BMI 27.2 ± 4.7 kg/m²) at a median of 3.1 years after transplantation. According to GLIM criteria, 14% was malnourished, of which 91% met the phenotypic criterion for reduced muscle mass. Similar results were found by using CHI as measure for muscle mass (13% malnutrition of which 79% with reduced muscle mass).

CONCLUSIONS

Malnutrition is present in one in 7 stable RTR, with reduced muscle mass as the predominant phenotypic criterion. Assessment of nutritional status, most importantly muscle status, is warranted in routine care, to prevent malnutrition in RTR from remaining undetected and untreated. The diagnostic value of 24-h urinary CER in this regard requires further investigation.

Physical activity and renal function in the Italian kidney transplant population

Background

The well-documented benefits of physical activity (PA) are still poorly characterized in long-term kidney transplant outcome. This study analyzed the impact over a 10-year follow-up of PA on graft function in Italian kidney transplant recipients (KTRs).

Methods

Since 2002, the Italian Transplant-Information-System collected donor and recipient baseline and transplant-related parameters in KTRs. In 2015, ‘penchant for PA’ (PA ≥ 30-min, 5 times/week) was added. Stable patients aged ≥18 years at the time of first-transplantation were eligible. KTRs with at least 10-year follow-up were also analyzed. Mixed-effect regression models were used to compare eGFR changes over time in active versus non-active patients.

Results

PA information was available for 6,055 KTRs (active 51.6%, non-active 48.4%). Lower penchant for PA was found in overweight and obese patients (OR = 0.84; OR = 0.48, respectively), in those with longer dialysis vintage (OR = 0.98 every year of dialysis), and older age at transplant. Male subjects showed greater penchant for PA (OR = 1.25). A slower decline of eGFR over time was observed in active KTRs compared to non-active, and this finding was confirmed in the subgroup with at least 10-year follow-up (n = 2,060). After applying the propensity score matching to reduce confounding factors, mixed-effect regression models corroborated such better long-term trend of graft function preservation in active KTRs.

Conclusions

Penchant for PA is more frequent among male and younger KTRs. Moreover, in our group of Italian KTRs, active patients revealed higher eGFR values and preserved kidney function over time, up to 10-years of follow-up.

Physical Activity and the Development of Post-Transplant Diabetes Mellitus, and Cardiovascular- and All-Cause Mortality in Renal Transplant Recipients

(1) Background: Little is currently known about the health impacts of daily-life moderate-to-vigorous physical activity (MVPA) in relation to the development of post-transplant diabetes mellitus (PTDM) and the long-term survival of renal transplant recipients (RTRs). (2) Methods: We analyzed self-reported data on MVPA within non-occupational and occupational domains, estimated with the SQUASH questionnaire, from a prospective cohort study of RTRs (n = 650) with a functioning graft exceeding 1 year. PTDM diagnoses were based on plasma glucose levels (≥126 mg/dL), HbA1c (≥6.5%), and the use of antidiabetic medication. Mortality data were retrieved from patient files up to the end of September 2015. (3) Results: During a median follow-up period of 5.3 years, 50 patients (10%) developed PTDM and 129 (19.8%) died. Of these deaths, 53 (8.9%) were caused by cardiovascular disease. Cox regression analyses showed that higher MVPA levels among patients were associated with a lower risk of PTDM (hazard ratio (HR); 95% confidence interval (95%CI) = 0.49; 0.25–0.96, p = 0.04), cardiovascular- (0.34; 0.15–0.77, p = 0.01), and all-cause mortality (0.37; 0.24–0.58, p < 0.001) compared with No-MVPA patients, independently of age, sex, and kidney function parameters. Associations of MVPA with cardiovascular and all-cause mortality remained significant and materially unchanged following further adjustments made for transplant characteristics, lifestyle factors, metabolic parameters, medication use, and creatinine excretion (muscle mass). However, the association between MVPA and PTDM was no longer significant after we adjusted for metabolic confounders and glucose levels. (4) Conclusion: Higher MVPA levels are associated with long-term health outcomes in RTRs.

Physical Activity and Cardiovascular Risk among Kidney Transplant Patients

PURPOSE

Research examining the relationship between physical activity (PA) and cardiovascular disease (CVD) risk factors among kidney transplant recipients (KTR) is limited. Accordingly, we sought to 1) describe the levels of PA in KTR and 2) analyze the associations between PA levels and CVD risk factors in KTR.

METHODS

Baseline data from KTR participants in a large multiethnic, multicenter trial (the Folic Acid for Vascular Outcome Reduction in Transplantation) were examined. PA was categorized in tertiles (low, moderate, and high) derived from a modified PA summary score from the Yale Physical Activity Survey. CVD risk factors were examined across levels of PA by ANOVA, Kruskal-Wallis rank test, and hierarchical multiple regression.

RESULTS

The 4034 participants were 37% female (mean ± SD = 51.9 ± 9.4 yr of age, 75% White, 97% with stage 2T-4T chronic kidney disease, and 20% with prevalent CVD. Participants in the "high" PA tertile reported more vigorous PA and walking, compared with participants in moderate and low tertiles (both P < 0.001). No differences were observed in daily household, occupational, or sedentary activities across PA tertiles. More participants in the "low" PA tertile were overweight/obese, had a history of prevalent diabetes, and/or had CVD compared with more active participants (all P < 0.001). Hierarchical modeling revealed that younger age (P = 0.002), cadaveric donor source (P = 0.006), shorter transplant vintage (P = 0.025), lower pulse pressure (P < 0.001), and no history of diabetes (P < 0.001) were associated with higher PA scores.

CONCLUSION

The most active KTR engaged in more intentional exercise. Lower levels of PA were positively associated with more CVD risk factors. Higher PA levels were associated with younger age and with more positive KTR outcomes.

Exercise as a prescription for patients with various diseases

A growing understanding of the benefits of exercise over the past few decades has prompted researchers to take an interest in the possibilities of exercise therapy. Because each sport has its own set of characteristics and physiological complications that tend to occur during exercise training, the effects and underlying mechanisms of exercise remain unclear. Thus, the first step in probing the effects of exercise on different diseases is the selection of an optimal exercise protocol. This review summarizes the latest exercise prescription treatments for 26 different diseases: musculoskeletal system diseases (low back pain, tendon injury, osteoporosis, osteoarthritis, and hip fracture), metabolic system diseases (obesity, type 2 diabetes, type 1 diabetes, and nonalcoholic fatty liver disease), cardio-cerebral vascular system diseases (coronary artery disease, stroke, and chronic heart failure), nervous system diseases (Parkinson's disease, Huntington's disease, Alzheimer's disease, depression, and anxiety disorders), respiratory system diseases (chronic obstructive pulmonary disease, interstitial lung disease, and after lung transplantation), urinary system diseases (chronic kidney disease and after kidney transplantation), and cancers (breast cancer, colon cancer, prostate cancer, and lung cancer). Each exercise prescription is displayed in a corresponding table. The recommended type, intensity, and frequency of exercise prescriptions are summarized, and the effects of exercise therapy on the prevention and rehabilitation of different diseases are discussed.

Prehabilitation prior to kidney transplantation: Results from a pilot study

Prehabilitation is the process of enhancing preoperative functional capacity to improve tolerance for the upcoming stressor; it was associated with improved postoperative outcomes in a handful of studies, but never evaluated in transplantation. Kidney transplant (KT) candidates may be uniquely suited for prehabilitation because they experience a profound loss of functional capacity while waiting years on dialysis. To better understand the feasibility and effectiveness of prehabilitation in KT, we conducted a pilot study of center-based prehabilitation for candidates; this intervention consisted of weekly physical therapy sessions at an outpatient center with at-home exercises. We enrolled 24 participants; 18 participated in prehabilitation (75% of enrolled; 17% of eligible). 61% were male, 72% were African American, and mean age = 52 (SD = 12.9); 71% of participants had lower-extremity impairment, and 31% were frail. By 2 months of prehabilitation, participants improved their physical activity by 64% (P = 0.004) based on accelerometry. Participants reported high satisfaction. Among 5 prehabilitation participants who received KT during the study, length of stay was shorter than for age-, sex-, and race-matched control (5 vs 10 days; RR = 0.69; 95% CI:0.50-0.94; P = 0.02). These pilot study findings suggest that prehabilitation is feasible in pretransplant patients and may potentially be a strategy to improve post-KT outcomes.

Prevalence and correlates of non-adherence to immunosuppressants and to health behaviours in patients after kidney transplantation in Brazil - the ADHERE BRAZIL multicentre study: a cross-sectional study protocol

BACKGROUND

Non-adherence to immunosuppressive therapy is a prevalent risk factor for poor clinical and after kidney transplantation (KT), and has contributed to the lack of improvement in long-term graft survival over the past decade. Understanding the multilevel correlates and risk factors of non-adherence is crucial to determine the optimal level for planning interventions, namely at the patient, health care provider, KT centre, and health care system level. Brazil, having the largest public transplantation program in the world and with regional differences regarding access to health services and service implementation, is in a unique position to study this multilevel approach. Therefore, the Adhere Brazil Study (ADHERE BRAZIL) was designed to assess the prevalence and variability of non-adherence to immunosuppressants and to health behaviours among adult KT recipients in Brazil, and to assess the multilevel correlates of non-adherence to immunosuppressive medication. We describe the rationale, design, and methodology of the ADHERE BRAZIL study.

METHODS/DESIGN

This is an observational, cross-sectional, multicentre study that includes 20 Brazilian KT centres. A stratified sampling approach is used, based on strata, with the following characteristics considered: geographical region and transplant activity (number of KTs per year). A random sample of patients (proportional to the size of the centre within each stratum) is selected from each centre. The prevalence of different health behaviours is assessed through self-report. The assessment of multilevel correlates of non-adherence is guided by the ecological model that considers factors at the level of the patient, health-care professional, and transplant centre, using established instruments or instruments developed for this study. Data will be collected over an 18-month period, with information obtained during the regular follow-up visits to the transplant outpatient clinic and directly entered into the Research Electronic Data Capture (RedCap) system. Data entry is performed by a trained professional who is part of the transplant team. The data collection began in December 2015.

DISCUSSION

This multicentre study is the first to evaluate multilevel correlates of non-adherence in KT patients and will provide a reliable estimate of non-adherence in Brazilian KT patients.

TRIAL REGISTRATION

ClinicalTrials.gov on 10/10/2013, NCT02066935 .

Physical activity and renal transplantation

Renal transplantation is burdened by high cardiovascular risk because of increased prevalence of traditional and disease-specific cardiovascular risk factors and, consequently, patients are affected by greater morbidity and mortality. In renal transplanted patients, healthy lifestyle and physical activity are recommended to improve overall morbidity and cardiovascular outcomes. According to METs (Metabolic Equivalent Task; i.e. the amount of energy consumed while sitting at rest), physical activities are classified as sedentary (<3.0 METs), of moderate-(3.0 to 5.9 METs) or vigorous-intensity (≥ 6.0 METs). Guidelines suggest for patients with chronic kidney disease an amount of physical activity of at least 30 minutes of moderate-intensity activity five times per week (min 450 MET-minutes/week). Data on physical activity in renal transplanted patients, however, are limited and have been mainly obtained by mean of non-objective methods. Available data suggest that physical activity is low either at the start or during renal transplantation and this may be associated with poor patient and graft outcomes. Therefore, in renal transplanted patients more data on physical activity obtained with objective, accelerometer-based methods are needed. In the meanwhile, physical activity have to be considered as an essential part of the medical care for renal transplanted recipients.

Physical activity in solid organ transplant recipients: preliminary results of the Italian project

BACKGROUND/AIMS

The role of physical activity in transplanted patients is often underestimated. We discuss the Italian National Transplant Centre experience, which started in 2008 studying transplanted patients involved in sports activities. The study was then developed through a model of cooperation between surgeons, sports physicians and exercise specialists.

METHODS

A multicentre study was realized in 120 transplanted patients of which 60 treated with supervised physical activity (three sessions/week of aerobic and strengthening exercises) and 60 controls. We present the results of the first 26 patients (16 males, 10 females; 47.8 ± 10.0 years; 21 kidney, 5 liver transplanted; time from transplant 2.3 ± 1.4 years) who completed 12 months of supervised physical activity.

RESULTS

Data showed an increase of peak aerobic power (t=4.535; P<0.01) and maximum workload (t=4.665; P<0.01) in the incremental cycling test. Maximum strength of knee extensors (t=2.933; P<0.05) and elbow flexors (t=2.450; P<0.05), and the power of lower limb (t=2.303; P<0.05) significantly increases. Health Related Quality of Life showed a significant improvement. Serum creatinine (1.4 ± 0.5 vs 1.3 ± 0.4 mg/dL) and proteinuria (0.10 ± 0.14 vs 0.08 ± 0.08 gr/dL) were stable.

CONCLUSION

These preliminary results confirm the positive effects of supervised physical exercise. It can be considered as an input to promote other detailed exercise protocols.

Food availability as a determinant of weight gain among renal transplant recipients

Excessive weight gain is common after renal transplantation, but it is unknown whether environmental factors, such as food availability, contribute to this important clinical problem. We evaluated the effects of food availability (fast food restaurants, convenience stores, and grocery stores within 1, 2, and 3 mile buffers of transplant recipients' residences) on body mass index (BMI) change during the first year post-transplant. Participants (n = 299) resided in Memphis, Tennessee. BMI increased by 1.42 units (p < .001) corresponding to an average weight gain of 9.25 lbs (5.43%) during the first year post-transplant. The number of grocery stores within 1 mile of recipient's residence was associated with an increase in BMI (p < .05), but fast food restaurants and convenience stores were not significantly associated with BMI change.

Development of Self-Management Scale for Kidney Transplant Recipients, Including Management of Post-Transplantation Chronic Kidney Disease

An evaluation scale is indispensable for the promotion of continuing, effective postkidney transplantation self-management behaviors. We aimed to develop and validate a new self-management scale for kidney transplant recipients to improve their long-term outcomes and prevent the recurrence of CKD complications. Two hundred and thirty-nine Japanese patients who had undergone kidney transplantation were recruited from three hospitals. The scale’s validity and reliability were evaluated using exploratory factor analysis and intraclass correlation coefficients. Scale items were selected by considering the findings of a clinical importance survey of 17 experts. Four subscales were identified by the factor analysis: “Self-monitoring” (six items), “Self-care behavior in daily living” (seven items), “Early detecting and coping with abnormalities after kidney transplantation” (four items), and “Stress management” (three items). Cronbach’s alpha coefficients for the subscales ranged from 0.61 to 0.87. A further four items with high clinical importance were added to the scale. The final scale comprised 24 items within four subscales and four single items. The intraclass correlation ranged from 0.88 to 0.95 in each subscale and the weighted kappa coefficient for the single items ranged from 0.33 to 0.72. The validity and reliability of our new self-management scale were confirmed by a patient-based field survey.

Exercise in kidney disease and diabetes: time for action

Physical inactivity is well recognised as a major health issue in today's society. Regular exercise is important in maintaining health and preventing chronic disease, it is increasingly accepted as a valuable therapeutic intervention in many long-term conditions. Unfortunately the role of physical activity in renal disease has been largely overlooked and provision of exercise advice and rehabilitation programmes for kidney patients lags well behind that of cardiology and pulmonary services. Research indicates that exercise can impact positively upon many of the health issues associated with declining renal function and renal replacement therapy, as concluded by a recent Cochrane review on the topic. As exercise should be integral to the management of diabetes, the issue is particularly relevant for patients with diabetic kidney disease. This paper summarises what is known about the main effects of exercise training in chronic kidney disease and diabetic kidney disease, and suggests how adaptations in the attitudes and approaches of the multidisciplinary renal and diabetes healthcare teams can help patients to enjoy the diverse benefits of an appropriately active lifestyle.

Cardiorespiratory fitness in young adults with a history of renal transplantation in childhood

Limited knowledge exists on cardiorespiratory fitness (CR fitness) in adults having a renal transplant (Rtx) during childhood. Our aim was to assess CR fitness (V0(2peak)) with a maximal treadmill test in former Rtx children reaching adulthood (ped-tx, n = 31), compared to patients Rtx as adults (adult-tx, n = 17) and healthy controls (HC, n = 36). Median age was 26.9 (19-41), 28.6 (23.5-34) and 33.5 (20-42) years, respectively. Median time since first Rtx was 18.1 (7-29) and 3.7 (1.2-12.6) years. Body composition was measured by dual-energy X-ray absorptiometry (DXA). V0(2peak) was median 37.9 (12.5-56.3), 40.8 (26.5-57.5), and 44.4 (29.5-65.6) ml kg (-1)min (-1) in the ped-tx, adult-tx, and HC, respectively. Ped-tx had significantly lower V0(2peak) compared to HC (p = 0.01). Adult-tx had higher exercise capacity (test duration) compared to ped-tx (median 10.5 (7.5-16) and 9 (6-14) min, respectively (p = 0.016). In multiple linear regression analysis, test duration, fat-free mass (FFM, kg) and Hgb (g/dl) were significant predictors of V0(2peak) explaining 86% of its variance. There was no significant difference between ped-tx and adult-tx in V0(2peak.) CR fitness depicts long-term health outcome in Rtx patients both in regard to physical functioning and is a plausible indirect marker of CV health.

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.