Association of self-reported physical function with survival in patients with chronic kidney disease

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

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

Can Functional Motor Capacity Influence Mortality in Advanced Chronic Kidney Disease Patients?

Alterations in the body's nutritional status or composition may be observed as the kidney disease advances, which could influence the kidney's functional capacity and, consequently, could increase the risk of mortality. The aim of the study is to determine the influence of functional capacity on mortality assessed by different functional tests in patients with advanced chronic kidney disease (ACKD). A prospective observational study was designed, which included 225 patients followed for 8 years in a CKD clinic. The study assessed functional capacity by using a range of tests, which included the Short Physical Performance Battery, the 6 minutes walking gait test, the timed up and go, and the four versions of the sit-to-stand test. Additionally, body composition and nutritional conditions were considered, taking into consideration various biochemical indicators such as albumin, prealbumin, c-reactive protein (CRP), lymphocytes, and transferrin, muscle strength, comorbidity, and frailty. The relationship between functionality and all-cause mortality was investigated using a Cox proportional hazard model. A total of fifty patients died during the duration of the study. Patients who performed worse on the function and muscle strength tests showed a worse body composition and nutritional status, and exhibited a reduced life expectancy. Inflammation (CRP) was associated with an increased risk of mortality (model 1: hazard ratio (HR) = 1.246; 95% confidence interval (95% CI = 1.014-1.531; model 2: HR = 1.333; 95% CI = 1.104-1.610). Good functional capacity as determined by the SPPB test decreased the risk of mortality (model 1: HR = 0.764; 95% CI = 0.683-0.855; model 2 HR = 0.778; 95% CI = 0.695-0.872). Cut-off points of maximum sensitivity and specificity for mortality were obtained with different tests. The study demonstrated that functional capacity influences mortality in patients with ACKD, being higher in those patients with impaired functionality regardless of the test used, although the SPPB allows a larger number of patients to be assessed. Therefore, it is essential to incorporate the assessment of functionality into the comprehensive care of patients with CKD.

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

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

Predicting a kidney transplant patient's pre-transplant functional status based on information from waitlist registration

With over 100,000 patients on the kidney transplant waitlist in 2019, it is important to understand if and how the functional status of a patient may change while on the waitlist. Recorded both at registration and just prior to transplantation, the Karnofsky Performance Score measures a patient's functional status and takes on values ranging from 0 to 100 in increments of 10. Using machine learning techniques, we built a gradient boosting regression model to predict a patient's pre-transplant functional status based on information known at the time of waitlist registration. The model's predictions result in an average root mean squared error of 12.99 based on 5 rolling origin cross validations and 12.94 in a separate out-of-time test. In comparison, predicting that the pre-transplant functional status remains the same as the status at registration, results in average root mean squared errors of 14.50 and 14.11 respectively. The analysis is based on 118,401 transplant records from 2007 to 2019. To the best of our knowledge, there has been no previously published research on building a model to predict kidney pre-transplant functional status. We also find that functional status at registration and total serum albumin, have the most impact in predicting the pre-transplant functional status.

Association of handgrip strength and/or walking pace with incident chronic kidney disease: A UK biobank observational study

BACKGROUND

The individual and combined relations of handgrip strength and walking pace with the risk of chronic kidney disease (CKD) remain uncertain. We aimed to investigate the relationship of handgrip strength and/or walking pace with incident CKD, using data from the large-scale, observational UK Biobank.

METHODS

A total of 417 504 participants free of prior kidney diseases were included from UK Biobank. Handgrip strength was assessed by dynamometer. The walking pace was self-reported as slow, average, or brisk. Cox proportional hazards models were applied to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for incident CKD.

RESULTS

The average age of the study population was 56.3 (SD, 8.1) years. 192 012 (46.0%) of the participants were male. The mean handgrip strength was 23.5 (SD, 6.2) and 40.0 (SD, 8.8) kg for females and males, respectively. Over a median follow-up duration of 12.1 years, 11 064 (2.7%) participants developed incident CKD. Handgrip strength was significantly inversely associated with the risk of incident CKD in both males and females (both P for trend <0.001). When handgrip strength was assessed as sex-specific quartiles, compared with those in the first quartile, the adjusted HRs (95% CI) of incident CKD in participants in the second, third and fourth quartiles were 0.84 (0.79, 0.89), 0.76 (0.71, 0.81) and 0.72 (0.67, 0.77), respectively. Compared with those with slow walking pace, participants with average (HR, 0.64; 95% CI: 0.60-0.68) or brisk (HR, 0.53; 95% CI: 0.49-0.57) walking pace had significantly lower risks of incident CKD. Compared with those with both lower handgrip strength (the first quartile) and slow walking pace, the lowest risk of incident CKD was observed in participants with both higher handgrip strength (the 2-4 quartiles) and average or brisk walking pace (HR, 0.51; 95% CI: 0.46-0.55).

CONCLUSIONS

Handgrip strength and walking pace were significantly inversely associated with incident CKD in the general population.

Association of nonpharmacologic chronic pain management with function in a low-income population: Evidence from a survey of a sample of Latinos from five states

BACKGROUND

Low-income minority populations often confront barriers to professional nonpharmacologic management of chronic pain and, without this care, may have poorer daily function.

OBJECTIVE

To examine the association of professional nonpharmacologic chronic pain management in the past year categorized as physical interventions or mind-body interventions with current functional status.

DESIGN

Online, population-based survey.

SETTING

Community-dwelling Latinos from five southwestern states (California, Texas, Arizona, Nevada, and New Mexico).

PARTICIPANTS

The survey was offered to all Latino online panel members aged 35 to 75 years in 5 states (N = 1007). With weights, this sample represented 11,016,135 persons. Of 516 respondents (51%), 486 (94%) had valid surveys and, of these, 102 members (21%) had chronic noncancer pain. With weights, they represented 1,140,170 persons with chronic pain.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Daily impairment in mobility and in activities of daily living (ADLs).

RESULTS

Of the weighted sample, 37.2% reported daily impairment in mobility and 29.4% in ADLs. Professional physical interventions for chronic pain were received by 41.2% and mind-body interventions received by 33.4% but usually with physical interventions. Adjusted odds ratios (AOR) of daily mobility impairment for respondents who used physical interventions with mind-body interventions or alone were both less than 0.10 (p < .01) versus none. Only professional physical intervention was associated with decreased odds for daily impairment in ADLs (AOR = 0.07; 95% confidence interval = 0.01 to 0.94; p = .045).

CONCLUSIONS

In a weighted sample of Latinos with chronic pain, professional physical interventions reduced the likelihood of daily impairment in mobility and ADLs.

A Narrative Review of Chronic Kidney Disease in Clinical Practice: Current Challenges and Future Perspectives

Chronic kidney disease (CKD) is a complex disease which affects approximately 13% of the world's population. Over time, CKD can cause renal dysfunction and progression to end-stage kidney disease and cardiovascular disease. Complications associated with CKD may contribute to the acceleration of disease progression and the risk of cardiovascular-related morbidities. Early CKD is asymptomatic, and symptoms only present at later stages when complications of the disease arise, such as a decline in kidney function and the presence of other comorbidities associated with the disease. In advanced stages of the disease, when kidney function is significantly impaired, patients can only be treated with dialysis or a transplant. With limited treatment options available, an increasing prevalence of both the elderly population and comorbidities associated with the disease, the prevalence of CKD is set to rise. This review discusses the current challenges and the unmet patient need in CKD.

Chronic Kidney Disease on Health-Related Quality of Life in Patients with Diabetes Mellitus: A National Representative Study

Importance: With an increasing prevalence of diabetes mellitus (DM) and comorbid chronic kidney disease (CKD), health-related quality of life (HRQoL) in patients with DM and CKD needs to be better understood. Objective: To investigate the association between the severity of CKD on HRQoL in DM patients. Design: A cross-sectional study of a nationally representative population-based survey, the Korea National Health and Nutrition Examination Survey (KNHANES). Setting: Data collected between 2007 and 2018 from the KNHANES. Participants: Adult participants with DM who completed the self-administered European Quality of Life Questionnaire Five Dimension (EQ-5D) questionnaire (n = 7243). Exposures: CKD stages defined by the Kidney Disease Improving Global System (KDIGO) staging system. Main Outcomes and Measures: We estimated the odds ratios (ORs) and 95% confidence intervals (CIs) of the presence of having problems in the 5 dimensions (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) of EQ-5D by CKD stage after adjusting for socio-demographic parameters and comorbid conditions. In addition, the EQ-5D index, reflecting the overall health status, was compared across CKD stages. Results: Among 7243 participants (mean (standard error) age 58.2 (0.2) 56.9% male), 24.0% (n = 1768) had CKD and 8.6% (n = 775) had stage 3–5 CKD. Pain/discomfort was the most common problem (30.5%) among patients with DM. Participants with more advanced CKD were more likely to experience problems in all dimensions of EQ-5D except the anxiety/depression dimension. In particular, compared to those without CKD, the adjusted ORs (95% CI) for any problem in the usual activities dimension was 1.65 (1.30, 2.10) in CKD stage 3 and 4.23 (2.07, 8.67) in CKD stage 4–5. Moreover, participants with stage 3 (−0.016 (−0.029, −0.003)) and stage 4–5 CKD (−0.088 (−0.129, −0.048)) had significantly lower EQ-5D index than those without CKD. However, compared with no CKD, CKD stage 1–2 was not significantly associated with having any problem in any dimensions. Conclusions and Relevance: In this nationally representative study, patients with DM had a high prevalence of self-reported poor HRQoL and the prevalence increased with more advanced stages of CKD. Therefore, assessment of HRQoL and interventions are necessary at early stages of CKD in DM patients.

Preoperative Cardiovascular Assessment of the Renal Transplant Recipient: A Narrative Review

Patients with end-stage kidney disease (ESKD) have a high prevalence of cardiovascular disease; it is the leading cause of death in these patients and the optimisation of their cardiovascular health may improve their post-transplant outcomes. Patients awaiting renal transplant often spend significant amounts of time on the waiting list allowing for the assessment and optimisation of their cardiovascular system. Coronary artery disease (CAD) is commonly seen in these patients and we explore the possible functional and anatomical investigations that can help assess and manage CAD in renal transplant candidates. We also discuss other aspects of cardiovascular assessment and management including arrhythmias, impaired ventricular function, valvular disease, lifestyle and pulmonary arterial hypertension. We hope that this review can form a basis for centres hoping to implement an enhanced recovery after surgery (ERAS) protocol for renal transplantation.

The impact of comorbid chronic kidney disease and diabetes on health-related quality-of-life: a 12-year community cohort study

BACKGROUND

Quality-of-life is an essential outcome for clinical care. Both chronic kidney disease (CKD) and diabetes have been associated with poorer quality-of-life. The combined impact of having both diseases is less well understood. As diabetes is the most common cause of CKD, it is imperative that we deepen our understanding of their joint impact.

METHODS

This was a prospective, longitudinal cohort study of community-based Australians aged ≥25 years who participated in the Australian Diabetes, Obesity and Lifestyle study. Quality-of-life was measured by physical component summary (PCS) and mental component summary sub-scores of the Short Form (36) Health Survey. Univariate and multivariate linear mixed effect regressions were performed.

RESULTS

Of the 11 081 participants with quality-of-life measurements at baseline, 1112 had CKD, 1001 had diabetes and of these 271 had both. Of the 1112 with CKD 421 had Stage 1, 314 had Stage 2, 346 had Stage 3 and 31 had Stages 4/5. Adjusted linear mixed effect models showed baseline PCS was lower for those with both CKD and diabetes compared with either disease alone (P < 0.001). Longitudinal analysis demonstrated a more rapid decline in PCS in those with both diseases.

CONCLUSIONS

The combination of CKD and diabetes has a powerful adverse impact on quality-of-life, and participants with both diseases had significantly poorer quality-of-life than those with one condition.

Personalized physical rehabilitation program and employment in kidney transplant recipients: a randomized trial

Kidney transplantation is the preferred treatment for kidney failure; however after transplant, reduced physical function, poor self-perceptions, and unemployment are common concerns that remain. This randomized controlled trial compared the effects of a 12-month exercise rehabilitation program (intervention) to standard care alone (control) in kidney transplant recipients. The exercise intervention consisted of a 2 day/week, 60-minute personalized, one-on-one, resistance-based exercise trainings. Eighty participants completed the study (52 intervention vs. 28 control). For individuals unemployed at baseline, there was a 52.3% increase in employment compared to 13.3 % increase in the control group after 12 months (P = <0.0001). For those already employed at baseline, 100% of individuals maintained employment in both groups after 12 months (P = 0.4742). For all comers, there was a positive trend for Global Physical Health (P = 0.0034), Global Mental Health (P = 0.0064), and Physical Function (P = 0.0075), with the intervention group showing greater improvements. These findings suggest the implementation of an exercise rehabilitation program postkidney transplant can be beneficial to increase employment for individuals previously unemployed, improve self-perceived health, physical function, and mental health, overall contributing to better health outcomes in kidney transplant recipients. (Clinicaltrials.gov number: NCT02409901).

Exercise training in chronic kidney disease-effects, expectations and adherence

There is increasing evidence showing the health benefits of physical activity, such as better survival and possibly even a slower decline in kidney function, in people with chronic kidney disease (CKD). There is convincing evidence that exercise training improves physical function measured as aerobic capacity, muscle endurance strength and balance at all ages and all stages of CKD. In fact, long-term adherence to well-designed and adequately monitored exercise training programmes is high. In general, patients express interest in exercise training and are motivated to improve their physical function and health. A growing number of nephrologists regard physical activity and exercise training as beneficial to patients with CKD. However, many feel that they do not have the knowledge to prescribe exercise training and suppose that patients are not interested. Patients state that support from healthcare professionals is crucial to motivate them to participate in exercise training programmes and overcome medical, physical and psychological barriers such as frailty, fatigue, anxiety and fear. Equally important is the provision of funding by healthcare providers to ensure adequate prescription and follow-up by trained exercise physiologists for this important non-pharmacological treatment.

Does Duke Activity Status Index help predicting functional exercise capacity and long-term prognosis in patients with pulmonary hypertension?

BACKGROUND

To investigate the association of Duke Activity Status Index (DASI) with 6-minute walk test (6MWT) and WHO-Functional Class (WHO-FC) in patients with pulmonary hypertension (PH), as well as exploring whether DASI can discriminate between the patients with better and worse long-term prognosis according to 400 m cut-off score in 6MWT.

METHODS

Eighty-five medically stable PH patients who met eligibility criteria were included. All patients were evaluated using 6MWT and DASI. The prognostic utility of the DASI was assessed using univariate linear regression and receiver operating characteristic (ROC) curve analysis.

RESULTS

The DASI was an independent predictor for both 6MWT and WHO-FC, explaining 50% of variance in 6MWT and 30% of variance in WHO-FC class (p < 0.001). In addition, DASI significantly correlated to 6MWT (r = 0.702) and WHO-FC class (r = 0.547). The ROC curve analysis revealed that the DASI had a discriminative value for identifying the patients with better long-term prognosis (p < 0.001), with an area under ROC curve of 0.867 [95% CI = 0.782-0.952]. The DASI ≥26 was the optimal cut-off value for better long-term prognosis, having sensitivity of 0.74 and a specificity of 0.88.

CONCLUSIONS

The DASI is a valid tool reflecting functional exercise capacity in patients with PH. Considering its ability to discriminate between the patients with better or worse long-term prognosis, it may help identifying the patients at higher risk.

The validity of the 'General Practice Physical Activity Questionnaire' against accelerometery in patients with chronic kidney disease

Background: The majority of patients with chronic kidney disease (CKD) are physically inactive. Simple yet accurate assessment of physical activity is important in identifying those in need of intervention. The 'General Practice Physical Activity Questionnaire' (GPPAQ) is a well-used clinical and research tool, but has not been validated.Methods: Forty individuals with CKD (age 62.5 (SD: 11.1) years, estimated glomerular filtration rate (eGFR) 33.2 (SD:19.1) ml/min/1.73 m²) completed the GPPAQ and objective physical activity was measured using a GENEActiv accelerometer for 7 days. Physical activity status was grouped as 'Active' (i.e. meeting current physical activity UK guidelines) or 'Inactive.' Sensitivity and specificity were calculated. Accuracy was defined as the probability the GPPAQ could correctly classify a patient as either 'Active' or 'Inactive' (based on accelerometery).Results: Using accelerometery, 18% of participants met the current UK guidelines, whereas 27% were classed as 'Active' according to GPPAQ. Sensitivity of the GPPAQ was 54.6% and specificity was 96.6%. The 'accuracy' of the GPPAQ was 85.0%. The accuracy of the GPPAQ was greater in males and those not in employment/retired, although these differences were not statistically significant.Conclusions: The GPPAQ may be a useful tool to identify CKD patients who would benefit most from a physical activity intervention. In particular, the GPPAQ can accurately identify those not sufficiently active.

Assessing physical activity and function in patients with chronic kidney disease: a narrative review

Physical activity potentially improves health outcomes in patients with chronic kidney disease (CKD) and recipients of kidney transplants. Although studies have demonstrated the beneficial effects of physical activity and exercise for primary and secondary prevention of non-communicable diseases, evidence for kidney patients is limited. To enlarge this evidence, valid assessment of physical activity and exercise is essential. Furthermore, CKD is associated with a decline in physical function, which may result in severe disabilities and dependencies. Assessment of physical function may help clinicians to monitor disease progression and frailty in patients receiving dialysis. The attention on physical function and physical activity has grown and new devices have been developed and (commercially) launched on the market. Therefore the aims of this review were to summarize different measures of physical function and physical activity, provide an update on measurement instruments and discuss options for easy-to-use measurement instruments for day-to-day use by CKD patients. This review demonstrates that large variation exists in the different strategies to assess physical function and activity in clinical practice and research settings. To choose the best available method, accuracy, content, preferable outcome, necessary expertise, resources and time are important issues to consider.

Sarcopenia in CKD: a roadmap from basic pathogenetic mechanisms to clinical trials

Sarcopenia and frailty are recognized as key risk factors for adverse outcomes in patients on renal replacement therapy or with non-dialysis chronic kidney disease (CKD). However, there is still debate about their pathogenesis and, thus, about the best therapeutic approaches, as well as the impact on outcomes of current approaches based on different exercise programmes. In the past two issues of Clinical Kidney Journal, several manuscripts address the issue of sarcopenia in CKD from the point of view of pathogenesis and new therapeutic approaches, monitoring of results, implementation of exercise programmes and specific potential benefits of exercise programmes in dialysis and non-dialysis CKD patients, as assessed by clinical trials.