1
|
Gollie JM, Ryan AS, Sen S, Patel SS, Kokkinos PF, Harris-Love MO, Scholten JD, Blackman MR. Exercise for patients with chronic kidney disease: from cells to systems to function. Am J Physiol Renal Physiol 2024; 326:F420-F437. [PMID: 38205546 PMCID: PMC11208028 DOI: 10.1152/ajprenal.00302.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/21/2023] [Accepted: 12/27/2023] [Indexed: 01/12/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Jared M Gollie
- Research and Development Service, Washington DC Veterans Affairs Medical Center, Washington, District of Columbia, United States
- Department of Health, Human Function, and Rehabilitation Sciences, The George Washington University, Washington, District of Columbia, United States
| | - Alice S Ryan
- Department of Medicine, University of Maryland, Baltimore, Maryland, United States
- Division of Geriatrics and Palliative Medicine, Baltimore Veterans Affairs Medical Center, Baltimore, Maryland, United States
| | - Sabyasachi Sen
- Department of Medicine, Washington DC Veterans Affairs, Medical Center, Washington, District of Columbia, United States
- Department of Medicine, The George Washington University, Washington, District of Columbia, United States
| | - Samir S Patel
- Research and Development Service, Washington DC Veterans Affairs Medical Center, Washington, District of Columbia, United States
- Department of Medicine, Washington DC Veterans Affairs, Medical Center, Washington, District of Columbia, United States
- Department of Medicine, The George Washington University, Washington, District of Columbia, United States
| | - Peter F Kokkinos
- Division of Cardiology, Washington DC Veterans Affairs Medical Center, Washington, District of Columbia, United States
- Department of Kinesiology and Health, Rutgers University, New Brunswick, New Jersey, United States
| | - Michael O Harris-Love
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
- Geriatric Research Education and Clinical Center, Eastern Colorado Veterans Affairs Health Care System, Denver, Colorado, United States
| | - Joel D Scholten
- Physical Medicine and Rehabilitation Service, Washington DC Veterans Affairs Medical Center, Washington, District of Columbia, United States
| | - Marc R Blackman
- Research and Development Service, Washington DC Veterans Affairs Medical Center, Washington, District of Columbia, United States
- Department of Medicine, Washington DC Veterans Affairs, Medical Center, Washington, District of Columbia, United States
- Department of Medicine, The George Washington University, Washington, District of Columbia, United States
- Department of Medicine, Georgetown University, Washington, District of Columbia, United States
- Department of Rehabilitation Medicine, Georgetown University, Washington, District of Columbia, United States
| |
Collapse
|
2
|
Sprick JD, Jeong J, Sabino-Carvalho JL, Li S, Park J. Neurocirculatory regulation and adaptations to exercise in chronic kidney disease. Am J Physiol Heart Circ Physiol 2023; 324:H843-H855. [PMID: 37000610 PMCID: PMC10191135 DOI: 10.1152/ajpheart.00115.2023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/23/2023] [Accepted: 03/29/2023] [Indexed: 04/01/2023]
Abstract
Chronic kidney disease (CKD) is characterized by pronounced exercise intolerance and exaggerated blood pressure reactivity during exercise. Classic mechanisms of exercise intolerance in CKD have been extensively described previously and include uremic myopathy, chronic inflammation, malnutrition, and anemia. We contend that these classic mechanisms only partially explain the exercise intolerance experienced in CKD and that alterations in cardiovascular and autonomic regulation also play a key contributing role. The purpose of this review is to examine the physiological factors that contribute to neurocirculatory dysregulation during exercise and discuss the adaptations that result from regular exercise training in CKD. Key neurocirculatory mechanisms contributing to exercise intolerance in CKD include augmentation of the exercise pressor reflex, aberrations in neurocirculatory control, and increased neurovascular transduction. In addition, we highlight how some contributing factors may be improved through exercise training, with a specific focus on the sympathetic nervous system. Important areas for future work include understanding how the exercise prescription may best be optimized in CKD and how the beneficial effects of exercise training may extend to the brain.
Collapse
Affiliation(s)
- Justin D Sprick
- Department of Kinesiology, Health Promotion and Recreation, University of North Texas, Denton, Texas, United States
| | - Jinhee Jeong
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States
- Department of Veterans Affairs Health Care System, Research Service Line, Decatur, Georgia, United States
| | - Jeann L Sabino-Carvalho
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States
- Department of Veterans Affairs Health Care System, Research Service Line, Decatur, Georgia, United States
| | - Sabrina Li
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States
- Department of Veterans Affairs Health Care System, Research Service Line, Decatur, Georgia, United States
| | - Jeanie Park
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States
- Department of Veterans Affairs Health Care System, Research Service Line, Decatur, Georgia, United States
| |
Collapse
|
3
|
D'Souza AW, Hissen SL, Okada Y, Jarvis SS, Washio T, Akins JD, Nelson DB, Fu Q. Differential regulation of sympathetic neural burst frequency and amplitude throughout normal pregnancy: a longitudinal study. Am J Physiol Regul Integr Comp Physiol 2023; 324:R249-R259. [PMID: 36534586 PMCID: PMC9902229 DOI: 10.1152/ajpregu.00239.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/29/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
Sympathetic activation is a hallmark of pregnancy. However, longitudinal assessments of muscle sympathetic nerve activity (MSNA) in pregnancy are scarce and have primarily focused on burst occurrence (frequency) at rest, despite burst strength (amplitude) representing distinct characteristics of sympathetic outflow. Thus, we assessed MSNA burst amplitude distributions in healthy women to determine the impact of normal pregnancy on neural discharge patterns in response to orthostatic stress. Twenty-six women were studied longitudinally during pre-, early- (4-8 wk of gestation), and late (32-36 wk) pregnancy, as well as postpartum (6-10 wk after delivery). MSNA, blood pressure (BP), and heart rate (HR) were measured in the supine posture and during graded head-up tilt (30° and 60° HUT). Mean and median MSNA burst amplitudes were used to characterize burst amplitude distribution. In late pregnancy, women demonstrated smaller increases in HR (P < 0.001) during 60° HUT and larger increases in systolic BP (P = 0.043) throughout orthostasis, compared with prepregnancy. The increase in MSNA burst frequency during late- relative to prepregnancy (Late: Δ14[10] vs. Pre: Δ21[9] bursts/min; P = 0.001) was smaller during 60° HUT, whereas increases in burst incidence were smaller in late- relative to prepregnancy throughout orthostasis (P = 0.009). Nonetheless, median burst amplitude was smaller throughout orthostasis in late compared with prepregnancy (P = 0.038). Thus, while supine MSNA burst frequency was greater in late pregnancy, increases in burst frequency and strength during orthostasis were attenuated. These smaller, orthostatically induced MSNA increases may reflect natural adaptions of pregnancy serving to prevent sympathetic hyper-reactivity that is common in pathological states.
Collapse
Affiliation(s)
- Andrew W D'Souza
- Neurovascular Research Laboratory, School of Kinesiology, Western University, London, Ontario, Canada
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sarah L Hissen
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yoshiyuki Okada
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Department of Special Care Dentistry, Hiroshima University, Hiroshima, Japan
| | - Sara S Jarvis
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Department of Biological Sciences, Northern Arizona University, Flagstaff, Arizona
| | - Takuro Washio
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - John D Akins
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - David B Nelson
- Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Qi Fu
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
4
|
Alvarez-Pitti J, Herceg-Čavrak V, Wójcik M, Radovanović D, Brzeziński M, Grabitz C, Wühl E, Drożdż D, Melk A. Blood pressure response to exercise in children and adolescents. Front Cardiovasc Med 2022; 9:1004508. [PMID: 36247478 PMCID: PMC9561233 DOI: 10.3389/fcvm.2022.1004508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/08/2022] [Indexed: 11/27/2022] Open
Abstract
Blood pressure changes during exercise are part of the physiological response to physical activity. Exercise stress testing can detect an exaggerated blood pressure response in children and adolescent. It is applied for certain clinical conditions, but is also commonly used as part of the assessment of athletes. The interpretation of blood pressure values in response to exercise during childhood and adolescence requires appropriate reference data. We discuss the available reference values and their limitations with regard to device, exercise protocol and normalization. While the link between an exaggerated blood pressure response and cardiovascular events and mortality has been demonstrated for adults, the situation is less clear for children and adolescents. We discuss the existing evidence and propose that under certain circumstances it might be reasonable to have children and adolescents undergo exercise stress testing as a rather non-invasive procedure to add additional information with regard to their cardiovascular risk profile. Based on the existing data future studies are needed to extend our current knowledge on possible links between the presence of certain clinical conditions, the detectability of an exaggerated blood pressure response during childhood and adolescence and the risk of developing cardiovascular morbidity and mortality in later life.
Collapse
Affiliation(s)
- Julio Alvarez-Pitti
- Pediatric Department, Consorcio Hospital General, University of Valencia, Valencia, Spain
- CIBER Fisiopatología Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
- INCLIVA Biomedical Research Institute, Hospital Clínico, University of Valencia, Valencia, Spain
| | - Vesna Herceg-Čavrak
- Faculty of Health Science, Libertas International University, Zagreb, Croatia
| | - Małgorzata Wójcik
- Department of Pediatric and Adolescent Endocrinology, Chair of Pediatrics, Pediatric Institute, Jagiellonian University Medical College, Kraków, Poland
| | - Dragan Radovanović
- Department of Medical Sciences, Faculty of Sport and Physical Education, University of Niš, Niš, Serbia
| | - Michał Brzeziński
- Department of Pediatrics, Gastroenterology, Allergology and Pediatric Nutrition, Medical University of Gdansk, Gdańsk, Poland
| | - Carl Grabitz
- Children’s Hospital, Hannover Medical School, Hanover, Germany
| | - Elke Wühl
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Dorota Drożdż
- Department of Pediatric Nephrology and Hypertension, Pediatric Institute, Jagiellonian University Medical College, Kraków, Poland
- Dorota Drożdż,
| | - Anette Melk
- Children’s Hospital, Hannover Medical School, Hanover, Germany
- *Correspondence: Anette Melk,
| |
Collapse
|
5
|
Teixeira AL, Vianna LC. The exercise pressor reflex: An update. Clin Auton Res 2022; 32:271-290. [PMID: 35727398 DOI: 10.1007/s10286-022-00872-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 05/25/2022] [Indexed: 02/07/2023]
Abstract
The exercise pressor reflex is a feedback mechanism engaged upon stimulation of mechano- and metabosensitive skeletal muscle afferents. Activation of these afferents elicits a reflex increase in heart rate, blood pressure, and ventilation in an intensity-dependent manner. Consequently, the exercise pressor reflex has been postulated to be one of the principal mediators of the cardiorespiratory responses to exercise. In this updated review, we will discuss classical and recent advancements in our understating of the exercise pressor reflex function in both human and animal models. Particular attention will be paid to the afferent mechanisms and pathways involved during its activation, its effects on different target organs, its potential role in the abnormal cardiovascular response to exercise in diseased states, and the impact of age and biological sex on these responses. Finally, we will highlight some unanswered questions in the literature that may inspire future investigations in the field.
Collapse
Affiliation(s)
- André L Teixeira
- NeuroV̇ASQ̇, Integrative Physiology Laboratory, Faculty of Physical Education, University of Brasília, DF, Brasília, Brazil
- Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, ON, Canada
| | - Lauro C Vianna
- NeuroV̇ASQ̇, Integrative Physiology Laboratory, Faculty of Physical Education, University of Brasília, DF, Brasília, Brazil.
| |
Collapse
|
6
|
Sprick JD, Mammino K, Jeong J, DaCosta DR, Hu Y, Morison DG, Nocera JR, Park J. Aerobic exercise training improves endothelial function and attenuates blood pressure reactivity during maximal exercise in chronic kidney disease. J Appl Physiol (1985) 2022; 132:785-793. [PMID: 35142559 PMCID: PMC8917938 DOI: 10.1152/japplphysiol.00808.2021] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Patients with chronic kidney disease (CKD) have exaggerated increases in blood pressure during exercise that are associated with endothelial dysfunction. We hypothesized that aerobic exercise training would improve endothelial function and attenuate blood pressure reactivity during exercise in CKD. Sedentary individuals with CKD stages III-IV underwent 12 wk of aerobic cycling exercise (n = 26) or nonaerobic exercise (n = 22, control). Both interventions were performed 3 days/wk and matched for duration. Endothelial function was measured via peripheral arterial tonometry and quantified as reactive hyperemia index (RHI). Peak oxygen uptake (V̇o2peak) was assessed via maximal treadmill exercise testing with concomitant blood pressure monitoring. All measurements were performed at baseline and after the 12-wk intervention. A linear mixed model was used to compare the rate of increase in blood pressure during the test. RHI improved with exercise (Pre = 1.78 ± 0.10 vs. Post = 2.01 ± 0.13, P = 0.03) with no change following stretching (Pre = 1.73 ± 0.08 vs. Post = 1.67 ± 0.10, P = 0.69). Peak systolic blood pressure during the maximal treadmill exercise test was lower after exercise training (Pre = 186 ± 5 mmHg, Post = 174 ± 4 mmHg, P = 0.003) with no change after stretching (Pre = 190 ± 6 mmHg, Post = 190 ± 4 mmHg, P = 0.12). The rate of increase in systolic blood pressure during the V̇o2peak test tended to decrease after training for both groups (-2 mmHg/stage) with no differences between groups (P = 0.97). There was no change in V̇o2peak after either intervention. In conclusion, aerobic exercise training improves endothelial function and attenuates peak blood pressure reactivity during exercise in CKD.NEW & NOTEWORTHY Patients with chronic kidney disease (CKD) exhibit increased blood pressure reactivity during exercise that is associated with endothelial dysfunction. Twelve weeks of structured, aerobic, exercise training improves endothelial function and attenuates peak blood pressure responses during exercise in CKD stages III-IV.
Collapse
Affiliation(s)
- Justin D. Sprick
- 1Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia,2Department of Veterans Affairs Health Care System, Decatur, Georgia,3Department of Veterans Affairs Health Care System, Center for Visual and Neurocognitive Rehabilitation, Decatur, Georgia
| | - Kevin Mammino
- 2Department of Veterans Affairs Health Care System, Decatur, Georgia,3Department of Veterans Affairs Health Care System, Center for Visual and Neurocognitive Rehabilitation, Decatur, Georgia
| | - Jinhee Jeong
- 1Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia,2Department of Veterans Affairs Health Care System, Decatur, Georgia,3Department of Veterans Affairs Health Care System, Center for Visual and Neurocognitive Rehabilitation, Decatur, Georgia
| | - Dana R. DaCosta
- 1Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia,2Department of Veterans Affairs Health Care System, Decatur, Georgia,3Department of Veterans Affairs Health Care System, Center for Visual and Neurocognitive Rehabilitation, Decatur, Georgia
| | - Yingtian Hu
- 4Department of Biostatistics and Bioinformatics, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Doree G. Morison
- 1Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia,2Department of Veterans Affairs Health Care System, Decatur, Georgia
| | - Joe R. Nocera
- 2Department of Veterans Affairs Health Care System, Decatur, Georgia,3Department of Veterans Affairs Health Care System, Center for Visual and Neurocognitive Rehabilitation, Decatur, Georgia,5Departments of Neurology and Rehabilitative Medicine, Emory University Department of Medicine, Atlanta, Georgia
| | - Jeanie Park
- 1Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia,2Department of Veterans Affairs Health Care System, Decatur, Georgia,3Department of Veterans Affairs Health Care System, Center for Visual and Neurocognitive Rehabilitation, Decatur, Georgia
| |
Collapse
|
7
|
Jeong JH, Sprick JD, DaCosta D, Quyyumi AA, Park J. Renin-Angiotensin System Blockade Is Associated with Exercise Capacity, Sympathetic Activity, and Endothelial Function in Patients with Chronic Kidney Disease. Kidney Blood Press Res 2021; 47:103-112. [PMID: 34758473 PMCID: PMC8844058 DOI: 10.1159/000520760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 11/01/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) patients have exercise intolerance and exaggerated blood pressure reactivity during exercise that are mediated by sympathetic nervous system (SNS) overactivation and decreased nitric oxide (NO) bioavailability. The activation of the renin-angiotensin system (RAS) increases SNS activation and reduces NO synthesis, and prior studies suggest that RAS blockade attenuates declines in physical function. We hypothesized that RAS inhibitor (RASi) use is associated with higher exercise capacity mediated by decreased SNS activity and increased NO-dependent endothelial function in CKD. METHOD In 35 CKD patients (57 ± 7 years) and 20 controls (CONs) (53 ± 8 years), we measured exercise capacity (peak oxygen consumption [VO2peak]), muscle sympathetic nervous activity (MSNA), and flow-mediated dilation (FMD) for NO-dependent endothelial function. RESULTS CKD patients treated with RASi (CKD + RASi, n = 25) had greater VO2peak than CKD patients not treated with RASi (CKD no RASi, n = 10), but lower VO2peak than CONs (23.3 ± 5.8 vs. 16.4 ± 2.9, p = 0.007; vs. 30.0 ± 7.7, p = 0.016 mL/min/kg, respectively). CKD + RASi had lower resting MSNA and greater FMD than CKD no RASi. Compared to CONs, CKD + RASi had similar MSNA but lower FMD. VO2peak was positively associated with FMD (r = 0.417, p = 0.038) and was predicted by the combination of FMD and RASi status (r2 = 0.344, p = 0.01) and MSNA and RASi status (r2 = 0.575, p = 0.040) in CKD patients. CONCLUSION In summary, CKD patients with RASi have higher exercise capacity than those not on RASi. Higher exercise capacity in the RASi-treated group was associated with lower resting SNS activity and higher NO-dependent vascular endothelial function.
Collapse
Affiliation(s)
- Jin Hee Jeong
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA,
- Research Service Line, Department of Veterans Affairs Health Care System, Decatur, Georgia, USA,
| | - Justin D Sprick
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Research Service Line, Department of Veterans Affairs Health Care System, Decatur, Georgia, USA
| | - Dana DaCosta
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Research Service Line, Department of Veterans Affairs Health Care System, Decatur, Georgia, USA
| | - Arshed A Quyyumi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jeanie Park
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Research Service Line, Department of Veterans Affairs Health Care System, Decatur, Georgia, USA
| |
Collapse
|
8
|
Kirkman DL, Bohmke N, Carbone S, Garten RS, Rodriguez-Miguelez P, Franco RL, Kidd JM, Abbate A. Exercise intolerance in kidney diseases: physiological contributors and therapeutic strategies. Am J Physiol Renal Physiol 2020; 320:F161-F173. [PMID: 33283641 DOI: 10.1152/ajprenal.00437.2020] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Exertional fatigue, defined as the overwhelming and debilitating sense of sustained exhaustion that impacts the ability to perform activities of daily living, is highly prevalent in chronic kidney disease (CKD) and end-stage renal disease (ESRD). Subjective reports of exertional fatigue are paralleled by objective measurements of exercise intolerance throughout the spectrum of the disease. The prevalence of exercise intolerance is clinically noteworthy, as it leads to increased frailty, worsened quality of life, and an increased risk of mortality. The physiological underpinnings of exercise intolerance are multifaceted and still not fully understood. This review aims to provide a comprehensive outline of the potential physiological contributors, both central and peripheral, to kidney disease-related exercise intolerance and highlight current and prospective interventions to target this symptom. In this review, the CKD-related metabolic derangements, cardiac and pulmonary dysfunction, altered physiological responses to oxygen consumption, vascular derangements, and sarcopenia are discussed in the context of exercise intolerance. Lifestyle interventions to improve exertional fatigue, such as aerobic and resistance exercise training, are discussed, and the lack of dietary interventions to improve exercise tolerance is highlighted. Current and prospective pharmaceutical and nutraceutical strategies to improve exertional fatigue are also broached. An extensive understanding of the pathophysiological mechanisms of exercise intolerance will allow for the development of more targeted therapeutic approached to improve exertional fatigue and health-related quality of life in CKD and ESRD.
Collapse
Affiliation(s)
- Danielle L Kirkman
- Department of Kinesiology and Health Sciences, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, Virginia
| | - Natalie Bohmke
- Department of Kinesiology and Health Sciences, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, Virginia
| | - Salvatore Carbone
- Department of Kinesiology and Health Sciences, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, Virginia.,Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Ryan S Garten
- Department of Kinesiology and Health Sciences, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, Virginia
| | - Paula Rodriguez-Miguelez
- Department of Kinesiology and Health Sciences, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, Virginia
| | - Robert L Franco
- Department of Kinesiology and Health Sciences, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, Virginia
| | - Jason M Kidd
- Division of Nephrology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Antonio Abbate
- Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia.,Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia
| |
Collapse
|
9
|
Hartwig CL, Sprick JD, Jeong J, Hu Y, Morison DG, Stein CM, Paranjape S, Park J. Increased vascular α1-adrenergic receptor sensitivity in older adults with posttraumatic stress disorder. Am J Physiol Regul Integr Comp Physiol 2020; 319:R611-R616. [PMID: 32966119 DOI: 10.1152/ajpregu.00155.2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Posttraumatic stress disorder (PTSD) is an independent risk factor for the development of hypertension and cardiovascular disease. Patients with PTSD have heightened blood pressure and sympathetic nervous system reactivity; however, it is unclear if patients with PTSD have exaggerated vasoconstriction in response to sympathetic nerve activation that could also contribute to increased blood pressure reactivity. Therefore, we hypothesized that patients with PTSD have increased sensitivity of vascular α1-adrenergic receptors (α1ARs), the major mediators of vasoconstriction in response to release of norepinephrine at sympathetic nerve terminals. To assess vascular α1AR sensitivity, we measured the degree of venoconstriction in a dorsal hand vein in response to exponentially increasing doses of the selective α1AR agonist, phenylephrine (PE), in 9 patients with PTSD (age = 59 ± 2 yr) and 10 age-matched controls (age = 60 ± 1 yr). Individual dose-response curves were generated to determine the dose of PE that induces 50% of maximal venoconstriction (i.e., PE ED50) reflective of vascular α1AR sensitivity. In support of our hypothesis, PE ED50 values were lower in PTSD compared with controls (245 ± 54 ng/min vs. 1,995 ± 459 ng/min, P = 0.012), indicating increased vascular α1AR sensitivity in PTSD. The PTSD group also had an increase in slope of rise in venoconstriction, indicative of an altered venoconstrictive reactivity to PE compared with controls (19.8% ± 1.2% vs. 15.1% ± 1.2%, P = 0.009). Heightened vascular α1AR sensitivity in PTSD may contribute to augmented vasoconstriction and blood pressure reactivity to sympathoexcitation and to increased cardiovascular disease risk in this patient population.
Collapse
Affiliation(s)
- Cortnie L Hartwig
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Department of Veterans Affairs Health Care System, Decatur, Georgia
| | - Justin D Sprick
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Department of Veterans Affairs Health Care System, Decatur, Georgia
| | - Jinhee Jeong
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Department of Veterans Affairs Health Care System, Decatur, Georgia
| | - Yingtian Hu
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Doree G Morison
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Department of Veterans Affairs Health Care System, Decatur, Georgia
| | - C Michael Stein
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sachin Paranjape
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeanie Park
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Department of Veterans Affairs Health Care System, Decatur, Georgia
| |
Collapse
|
10
|
Sympathetic nerve traffic overactivity in chronic kidney disease: a systematic review and meta-analysis. J Hypertens 2020; 39:408-416. [PMID: 33031182 DOI: 10.1097/hjh.0000000000002661] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Studies based on microneurographic sympathetic nerve activity (MSNA) recordings have shown that the sympathetic system is overactivated in chronic kidney disease (CKD) patients but the relationship between MSNA and renal function and other risk factors has not been systematically reviewed in this population. DESIGN AND MEASUREMENTS This meta-analysis compares MSNA in cardiovascular complications-free CKD patients (n = 638) and healthy individuals (n = 372) and assesses the relationship of MSNA with the eGFR, age, BMI and hemodynamic variables. RESULTS In a global analysis, MSNA was higher in CKD patients than in healthy control individuals (P < 0.001). The difference in MSNA between patients and healthy individuals was more marked in end-stage kidney diseases patients than in stage 3A 3B CKD patients (P < 0.001). In an analysis combining patients and healthy individuals, MSNA rose gradually across progressively lower eGFR categories (P < 0.01). In separate meta-regression analyses in CKD patients and in healthy individuals, MSNA associated directly with age (CKD: r = 0.57, P = 0.022; healthy individuals: r = 0.71, P = 0.031) and with the BMI (r = 0.75, P = 0.001 and r = 0.93, P = 0.003). In both groups, MSNA correlated with heart rate (r = 0.77, P = 0.02 and r = 0.66, P = 0.01) but was unrelated to plasma norepinephrine. CONCLUSION Independently of comorbidities, MSNA is markedly increased in CKD patients as compared with healthy individuals and it is related to renal function, age, the BMI and heart rate. Sympathetic activation intensifies as CKD progresses toward kidney failure and such an intensification is paralleled by a progressive rise in heart rate but it is not reflected by plasma norepinephrine.
Collapse
|
11
|
Drew RC, Charkoudian N, Park J. Neural control of cardiovascular function in black adults: implications for racial differences in autonomic regulation. Am J Physiol Regul Integr Comp Physiol 2019; 318:R234-R244. [PMID: 31823675 DOI: 10.1152/ajpregu.00091.2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Black adults are at increased risk for developing hypertension and cardiovascular and chronic kidney disease and have greater associated morbidity/mortality than white adults who are otherwise demographically similar. Despite the key role of the autonomic nervous system in the regulation of cardiovascular function, the mechanistic contributions of sympathetic nerves to racial differences in cardiovascular dysfunction and disease remain poorly understood. In this review, we present an update and synthesis of current understanding regarding the roles of autonomic neural mechanisms in normal and pathophysiological cardiovascular control in black and white adults. At rest, many hemodynamic and autonomic variables, including blood pressure, cardiac output, and sympathetic nerve activity, are similar in healthy black and white adults. However, resting sympathetic vascular transduction and carotid baroreflex responses are altered in ways that tend to promote increased vasoconstriction and higher blood pressure, even in healthy, normotensive black adults. Acute sympathoexcitatory maneuvers, including exercise and cold pressor test, often result in augmented sympathetic and hemodynamic responses in healthy black adults. Clinically, although mechanistic evidence is scarce in this area, existing data support the idea that excessive sympathetic activation and/or transduction into peripheral vasoconstriction contribute importantly to the pathophysiology of hypertension and chronic kidney disease in black compared with white adults. Important areas for future work include more detailed study of sympathetic and hemodynamic reactivity to exercise and other stressors in male and female black adults and, particularly, sympathetic control of renal function, an important area of clinical concern in black patients.
Collapse
Affiliation(s)
- Rachel C Drew
- Department of Exercise and Health Sciences, University of Massachusetts Boston, Boston, Massachusetts
| | - Nisha Charkoudian
- Thermal and Mountain Medicine Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts
| | - Jeanie Park
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Atlanta Veterans Affairs Health Care System, Decatur, Georgia
| |
Collapse
|
12
|
Vianna LC, Fisher JP. Reflex control of the cardiovascular system during exercise in disease. CURRENT OPINION IN PHYSIOLOGY 2019. [DOI: 10.1016/j.cophys.2019.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|
13
|
Sprick JD, Morison DL, Fonkoue IT, Li Y, DaCosta D, Rapista D, Choi H, Park J. Metabolic acidosis augments exercise pressor responses in chronic kidney disease. Am J Physiol Regul Integr Comp Physiol 2019; 317:R312-R318. [PMID: 31141417 DOI: 10.1152/ajpregu.00076.2019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Chronic kidney disease (CKD) patients experience augmented blood pressure (BP) reactivity during exercise that is associated with an increased risk of cardiovascular mortality. Exaggerated exercise pressor responses in CKD are in part mediated by augmented sympathetic nerve activation due to heightened muscle mechanoreflex. One mechanism that may lead to sensitization of the muscle mechanoreflex in CKD is metabolic acidosis. We hypothesized that CKD patients with low serum [bicarbonate] would exhibit exaggerated increases in arterial BP, greater reductions in muscle interstitial pH, and fatigue earlier during exercise compared with CKD patients with normal serum bicarbonate concentration ([bicarbonate]). Eighteen CKD participants with normal serum [bicarbonate] (≥24 mmol/l, normal-bicarb) and 9 CKD participants with mild metabolic acidosis ([bicarbonate] range 20-22 mmol/l, low-bicarb) performed rhythmic handgrip (RHG) exercise to volitional fatigue at 40% of maximal voluntary contraction. BP, heart rate, and muscle interstitial pH using near infrared spectroscopy were measured continuously. While mean arterial pressure (MAP) increased with exercise in both groups (P ≤ 0.002), CKD with low-bicarb had an exaggerated MAP response compared with CKD with normal-bicarb (+5.9 ± 1.3 mmHg/30 s vs. +2.6 ± 0.5 mmHg/30 s, P = 0.01). The low-bicarb group reached exhaustion earlier than the normal-bicarb group (179 ± 21 vs. 279 ± 19 s, P = 0.003). There were no differences in the change in muscle interstitial pH during exercise between groups (P = 0.31). CKD patients with metabolic acidosis have augmented exercise-induced increases in BP and poorer exercise tolerance. There was no difference in change in muscle interstitial pH between groups, however, suggesting that augmented exercise BP responses in metabolic acidosis are not due to impaired muscle-buffering capacity.
Collapse
Affiliation(s)
- Justin D Sprick
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Department of Veterans Affairs Health Care System, Decatur, Georgia
| | - Doree Lynn Morison
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Department of Veterans Affairs Health Care System, Decatur, Georgia
| | - Ida T Fonkoue
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Department of Veterans Affairs Health Care System, Decatur, Georgia
| | - Yunxiao Li
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Dana DaCosta
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Department of Veterans Affairs Health Care System, Decatur, Georgia
| | - Derick Rapista
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Department of Veterans Affairs Health Care System, Decatur, Georgia
| | - HyunKyu Choi
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Jeanie Park
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Department of Veterans Affairs Health Care System, Decatur, Georgia
| |
Collapse
|
14
|
The effect of exercise on blood pressure in chronic kidney disease: A systematic review and meta-analysis of randomized controlled trials. PLoS One 2019; 14:e0211032. [PMID: 30726242 PMCID: PMC6364898 DOI: 10.1371/journal.pone.0211032] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 01/07/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Management of hypertension in chronic kidney disease (CKD) remains a major challenge. We conducted a systematic review to assess whether exercise is an effective strategy for lowering blood pressure in this population. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS We searched MEDLINE, EMBASE, the Cochrane Library, CINAHL and Web of Science for randomized controlled trials (RCTs) that examined the effect of exercise on blood pressure in adults with non-dialysis CKD, stages 3-5. Outcomes were non-ambulatory systolic blood pressure (primary), other blood pressure parameters, 24-hour ambulatory blood pressure, pulse-wave velocity, and flow-mediated dilatation. Results were summarized using random effects models. RESULTS Twelve studies with 505 participants were included. Ten trials (335 participants) reporting non-ambulatory systolic blood pressure were meta-analysed. All included studies were a high risk of bias. Using the last available time point, exercise was not associated with an effect on systolic blood pressure (mean difference, MD -4.33 mmHg, 95% confidence interval, CI -9.04, 0.38). The MD after 12-16 and 24-26 weeks of exercise was significant (-4.93 mmHg, 95% CI -8.83, -1.03 and -10.94 mmHg, 95% CI -15.83, -6.05, respectively) but not at 48-52 weeks (1.07 mmHg, 95% CI -6.62, 8.77). Overall, exercise did not have an effect on 24-hour ambulatory blood pressure (-5.40 mmHg, 95% CI -12.67, 1.87) or after 48-52 weeks (-7.50 mmHg 95% CI -20.21, 5.21) while an effect was seen at 24 weeks (-18.00 mmHg, 95% CI -29.92, -6.08). Exercise did not have a significant effect on measures of arterial stiffness or endothelial function. CONCLUSION Limited evidence from shorter term studies suggests that exercise is a potential strategy to lower blood pressure in CKD. However, to recommend exercise for blood pressure control in this population, high quality, longer term studies specifically designed to evaluate hypertension are needed.
Collapse
|
15
|
Jeong JH, Biruete A, Fernhall B, Wilund KR. Effects of acute intradialytic exercise on cardiovascular responses in hemodialysis patients. Hemodial Int 2018; 22:524-533. [PMID: 29745006 PMCID: PMC10463186 DOI: 10.1111/hdi.12664] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 03/04/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND In patients with kidney failure requiring hemodialysis (HD) treatment, intradialytic exercise (IDEX) has been advocated for its feasibility and effectiveness in improving important health outcomes. However, IDEX as an adjunct therapeutic strategy is infrequently implemented, in part due to potential risks of IDEX, especially in patients with chronic volume overload. This study was performed to evaluate the safety of IDEX performed at different time points by examining its effect on intradialytic cardiovascular hemodynamics. METHODS In a randomized cross-over study (n = 12), intradialytic changes in brachial, aortic, and cardiac hemodynamics and autonomic function were examined during a HD session; (1) without exercise; (2) with 30 min of IDEX performed in the first hour of treatment; or (3) with 30 min of IDEX in the third hour of treatment. RESULTS IDEX during either the first or third hour did not exacerbate hemodynamic instability during treatment regardless of patient's hydrations status. While there were transient increases in stroke volume, cardiac output, and heart rate during IDEX, intradialytic changes in brachial and aortic blood pressure, cardiac hemodynamics, and autonomic function were similar on days with and without IDEX. CONCLUSION These results indicate that IDEX does not exacerbate hemodynamic instability during HD, regardless of a patient's hydration status or the timing of exercise.
Collapse
Affiliation(s)
- Jin Hee Jeong
- Department of Kinesiology and Community Health, Urbana, Illinois, USA
| | - Annabel Biruete
- Division of Nutritional Sciences, University of Illinois, Urbana-Champaign, Urbana, Illinois, USA
| | - Bo Fernhall
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Kenneth R Wilund
- Department of Kinesiology and Community Health, Urbana, Illinois, USA
| |
Collapse
|
16
|
Afsar B, Siriopol D, Aslan G, Eren OC, Dagel T, Kilic U, Kanbay A, Burlacu A, Covic A, Kanbay M. The impact of exercise on physical function, cardiovascular outcomes and quality of life in chronic kidney disease patients: a systematic review. Int Urol Nephrol 2018; 50:885-904. [DOI: 10.1007/s11255-018-1790-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 01/07/2018] [Indexed: 12/18/2022]
|
17
|
Matthews EL, Brian MS, Edwards DG, Stocker SD, Wenner MM, Farquhar WB. Blood pressure responses to dietary sodium: Association with autonomic cardiovascular function in normotensive adults. Auton Neurosci 2017; 208:51-56. [PMID: 28802637 PMCID: PMC5739975 DOI: 10.1016/j.autneu.2017.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 06/13/2017] [Accepted: 08/04/2017] [Indexed: 11/28/2022]
Abstract
Blood pressure responses to dietary sodium vary widely person-to-person. Salt sensitive rodent models display altered autonomic function, a trait thought to contribute to poor cardiovascular health. Thus, we hypothesized that increased salt sensitivity (SS) in normotensive humans would be associated with increased muscle sympathetic nerve activity (MSNA), decreased high frequency heart rate variability (HF-HRV), and decreased baroreflex sensitivity. Healthy normotensive men and women completed 1week of high (300mmol·day-1) and 1week of low (20mmol·day-1) dietary sodium (random order) with 24h mean arterial pressure (MAP) assessed on the last day of each diet to assess SS. Participants returned to the lab under habitual sodium conditions for testing. Forty-two participants are presented in this analysis, 19 of which successful MSNA recordings were obtained (n=42: age 39±2yrs., BMI 24.3±0.5kg·(m2)-1, MAP 83±1mmHg, habitual urine sodium 93±7mmol·24h-1; n=19: MSNA burst frequency 20±2 bursts·min-1). The variables of interest were linearly regressed over the magnitude of SS. Higher SS was associated with increased MSNA (burst frequency: r=0.469, p=0.041), decreased HF-HRV (r=-0.349, p=0.046), and increased LF/HF-HRV (r=0.363, p=0.034). SS was not associated with sympathetic or cardiac baroreflex sensitivity (p>0.05). Multiple regression analysis accounting for age found that age, not SS, independently predicted HF-HRV (age adjusted no longer significant; p=0.369) and LF/HF-HRV (age adjusted p=0.273). These data suggest that age-related salt sensitivity of blood pressure in response to dietary sodium is associated with altered resting autonomic cardiovascular function.
Collapse
Affiliation(s)
- Evan L Matthews
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA; Department of Exercise Science and Physical Education, Montclair State University, Montclair, NJ, USA.
| | - Michael S Brian
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA.
| | - David G Edwards
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA.
| | - Sean D Stocker
- Department of Medicine, Division of Renal-Electrolyte, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Megan M Wenner
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA.
| | - William B Farquhar
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA.
| |
Collapse
|
18
|
Drew RC. Baroreflex and neurovascular responses to skeletal muscle mechanoreflex activation in humans: an exercise in integrative physiology. Am J Physiol Regul Integr Comp Physiol 2017; 313:R654-R659. [PMID: 28855178 DOI: 10.1152/ajpregu.00242.2017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 08/07/2017] [Accepted: 08/23/2017] [Indexed: 12/13/2022]
Abstract
Cardiovascular adjustments to exercise resulting in increased blood pressure (BP) and heart rate (HR) occur in response to activation of several neural mechanisms: the exercise pressor reflex, central command, and the arterial baroreflex. Neural inputs from these feedback and feedforward mechanisms integrate in the cardiovascular control centers in the brain stem and modulate sympathetic and parasympathetic neural outflow, resulting in the increased BP and HR observed during exercise. Another specific consequence of the central neural integration of these inputs during exercise is increased sympathetic neural outflow directed to the kidneys, causing renal vasoconstriction, a key reflex mechanism involved in blood flow redistribution during increased skeletal muscle work. Studies in humans have shown that muscle mechanoreflex activation inhibits cardiac vagal outflow, decreasing the sensitivity of baroreflex control of HR. Metabolite sensitization of muscle mechanoreceptors can lead to reduced sensitivity of baroreflex control of HR, with thromboxane being one of the metabolites involved, via greater inhibition of cardiac vagal outflow without affecting baroreflex control of BP or baroreflex resetting. Muscle mechanoreflex activation appears to play a predominant role in causing renal vasoconstriction, both in isolation and in the presence of local metabolites. Limited investigations in older adults and patients with cardiovascular-related disease have provided some insight into how the influence of muscle mechanoreflex activation on baroreflex function and renal vasoconstriction is altered in these populations. However, future research is warranted to better elucidate the specific effect of muscle mechanoreflex activation on baroreflex and neurovascular responses with aging and cardiovascular-related disease.
Collapse
Affiliation(s)
- Rachel C Drew
- Department of Exercise and Health Sciences, University of Massachusetts Boston, Boston, Massachusetts
| |
Collapse
|
19
|
Downey RM, Liao P, Millson EC, Quyyumi AA, Sher S, Park J. Endothelial dysfunction correlates with exaggerated exercise pressor response during whole body maximal exercise in chronic kidney disease. Am J Physiol Renal Physiol 2017; 312:F917-F924. [PMID: 28274927 DOI: 10.1152/ajprenal.00603.2016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 02/24/2017] [Accepted: 02/27/2017] [Indexed: 02/07/2023] Open
Abstract
Chronic kidney disease (CKD) patients have exercise intolerance associated with increased cardiovascular mortality. Previous studies demonstrate that blood pressure (BP) and sympathetic nerve responses to handgrip exercise are exaggerated in CKD. These patients also have decreased nitric oxide (NO) bioavailability and endothelial dysfunction, which could potentially lead to an impaired ability to vasodilate during exercise. We hypothesized that CKD patients have exaggerated BP responses during maximal whole body exercise and that endothelial dysfunction correlates with greater exercise pressor responses in these patients. Brachial artery flow-mediated dilation (FMD) was assessed before maximal treadmill exercise in 56 participants: 38 CKD (56.7 ± 1.2 yr old, 38 men) and 21 controls (52.8 ± 1.8 yr old, 20 men). During maximal treadmill exercise, the slope-of-rise in systolic BP (+10.32 vs. +7.75 mmHg/stage, P < 0.001), mean arterial pressure (+3.50 vs. +2.63 mmHg/stage, P = 0.004), and heart rate (+11.87 vs. +10.69 beats·min-1·stage-1, P = 0.031) was significantly greater in CKD compared with controls. Baseline FMD was significantly lower in CKD (2.76 ± 0.42% vs. 5.84 ± 0.97%, P = 0.008). Lower FMD values were significantly associated with a higher slope-of-rise in systolic BP (+11.05 vs. 8.71 mmHg/stage, P = 0.003) during exercise in CKD, as well as poorer exercise capacity measured as peak oxygen uptake (V̇o2peak; 19.47 ± 1.47 vs. 24.57 ± 1.51 ml·min-1·kg-1, P < 0.001). These findings demonstrate that low FMD in CKD correlates with augmented BP responses during exercise and lower V̇o2peak, suggesting that endothelial dysfunction may contribute to exaggerated exercise pressor responses and poor exercise capacity in CKD patients.
Collapse
Affiliation(s)
- Ryan M Downey
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Research Service Line, Department of Veterans Affairs Medical Center, Decatur, Georgia
| | - Peizhou Liao
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Erin C Millson
- Clinical Research Network, Atlanta Clinical and Translational Science Institute, Emory University School of Medicine, Atlanta, Georgia; and
| | - Arshed A Quyyumi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Salman Sher
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Jeanie Park
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; .,Research Service Line, Department of Veterans Affairs Medical Center, Decatur, Georgia
| |
Collapse
|
20
|
Didier KD, Ederer AK, Reiter LK, Brown M, Hardy R, Caldwell J, Black C, Bemben MG, Ade CJ. Altered Blood Flow Response to Small Muscle Mass Exercise in Cancer Survivors Treated With Adjuvant Therapy. J Am Heart Assoc 2017; 6:JAHA.116.004784. [PMID: 28174169 PMCID: PMC5523772 DOI: 10.1161/jaha.116.004784] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background Adjuvant cancer treatments have been shown to decrease cardiac function. In addition to changes in cardiovascular risk, there are several additional functional consequences including decreases in exercise capacity and increased incidence of cancer‐related fatigue. However, the effects of adjuvant cancer treatment on peripheral vascular function during exercise in cancer survivors have not been well documented. We investigated the vascular responses to exercise in cancer survivors previously treated with adjuvant cancer therapies. Methods and Results Peripheral vascular responses were investigated in 11 cancer survivors previously treated with adjuvant cancer therapies (age 58±6 years, 34±30 months from diagnosis) and 9 healthy controls group matched for age, sex, and maximal voluntary contraction. A dynamic handgrip exercise test at 20% maximal voluntary contraction was performed with simultaneous measurements of forearm blood flow and mean arterial pressure. Forearm vascular conductance was calculated from forearm blood flow and mean arterial pressure. Left ventricular ejection time index (LVETi) was derived from the arterial pressure wave form. Forearm blood flow was attenuated in cancer therapies compared to control at 20% maximal voluntary contraction (189.8±53.8 vs 247.9±80.3 mL·min−1, respectively). Forearm vascular conductance was not different between groups at rest or during exercise. Mean arterial pressure response to exercise was attenuated in cancer therapies compared to controls (107.8±10.8 vs 119.2±16.2 mm Hg). LEVTi was lower in cancer therapies compared to controls. Conclusions These data suggest an attenuated exercise blood flow response in cancer survivors ≈34 months following adjuvant cancer therapy that may be attributed to an attenuated increase in mean arterial pressure.
Collapse
Affiliation(s)
- Kaylin D Didier
- Department of Health and Exercise Science, The University of Oklahoma, Norman, OK.,Department of Kinesiology, Kansas State University, Manhattan, KS
| | - Austin K Ederer
- Department of Health and Exercise Science, The University of Oklahoma, Norman, OK
| | - Landon K Reiter
- Department of Health and Exercise Science, The University of Oklahoma, Norman, OK
| | - Michael Brown
- Department of Health and Exercise Science, The University of Oklahoma, Norman, OK
| | - Rachel Hardy
- Department of Health and Exercise Science, The University of Oklahoma, Norman, OK
| | - Jacob Caldwell
- Department of Health and Exercise Science, The University of Oklahoma, Norman, OK.,Department of Kinesiology, Kansas State University, Manhattan, KS
| | - Christopher Black
- Department of Health and Exercise Science, The University of Oklahoma, Norman, OK
| | - Michael G Bemben
- Department of Health and Exercise Science, The University of Oklahoma, Norman, OK
| | - Carl J Ade
- Department of Health and Exercise Science, The University of Oklahoma, Norman, OK .,Department of Kinesiology, Kansas State University, Manhattan, KS
| |
Collapse
|
21
|
Mizuno M, Mitchell JH, Crawford S, Huang CL, Maalouf N, Hu MC, Moe OW, Smith SA, Vongpatanasin W. High dietary phosphate intake induces hypertension and augments exercise pressor reflex function in rats. Am J Physiol Regul Integr Comp Physiol 2016; 311:R39-48. [PMID: 27170660 PMCID: PMC4967233 DOI: 10.1152/ajpregu.00124.2016] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 05/06/2016] [Indexed: 01/14/2023]
Abstract
An increasing number of studies have linked high dietary phosphate (Pi) intake to hypertension. It is well established that the rise in sympathetic nerve activity (SNA) and blood pressure (BP) during physical exertion is exaggerated in many forms of hypertension, which are primarily mediated by an overactive skeletal muscle exercise pressor reflex (EPR). However, it remains unknown whether high dietary Pi intake potentiates the EPR-mediated SNA and BP response to exercise. Accordingly, we measured renal SNA (RSNA) and mean BP (MBP) in normotensive Sprague-Dawley rats fed a normal Pi diet (0.6%, n = 13) or high Pi diet (1.2%, n = 13) for 3 mo. As previously reported, we found that resting BP was significantly increased by 1.2% Pi diet in both conscious and anesthetized animals. Activation of the EPR by electrically induced hindlimb contraction triggered greater increases in ΔRSNA and ΔMBP in the 1.2% compared with 0.6% Pi group (126 ± 25 vs. 42 ± 9%; 44 ± 5 vs. 14 ± 2 mmHg, respectively, P < 0.01). Activation of the muscle mechanoreflex, a component of the EPR, by passively stretching hindlimb muscle also evoked greater increases in ΔRSNA and ΔMBP in the 1.2% compared with 0.6% Pi group (109 ± 27 vs. 24 ± 7%, 38 ± 7 vs. 8 ± 2 mmHg, respectively, P < 0.01). A similar response was produced by hindlimb intra-arterial capsaicin administration to stimulate the metaboreflex arm of the EPR. Thus, our data demonstrate a novel action of dietary Pi loading in augmenting EPR function through overactivation of both the muscle mechanoreflex and metaboreflex.
Collapse
Affiliation(s)
- Masaki Mizuno
- Department of Health Care Sciences, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Cardiology Division, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jere H Mitchell
- Cardiology Division, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Scott Crawford
- Department of Health Care Sciences, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Chou-Long Huang
- Nephrology Division, University of Texas Southwestern Medical Center, Dallas, Texas; Charles and Jane Pak Center of Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Naim Maalouf
- Mineral Metabolism Division, University of Texas Southwestern Medical Center, Dallas, Texas; and Charles and Jane Pak Center of Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ming-Chang Hu
- Mineral Metabolism Division, University of Texas Southwestern Medical Center, Dallas, Texas; and Charles and Jane Pak Center of Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Orson W Moe
- Nephrology Division, University of Texas Southwestern Medical Center, Dallas, Texas; Charles and Jane Pak Center of Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Scott A Smith
- Department of Health Care Sciences, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Cardiology Division, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Wanpen Vongpatanasin
- Cardiology Division, University of Texas Southwestern Medical Center, Dallas, Texas; Hypertension Section, University of Texas Southwestern Medical Center, Dallas, Texas; Charles and Jane Pak Center of Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
22
|
Lin AM, Liao P, Millson EC, Quyyumi AA, Park J. Tetrahydrobiopterin ameliorates the exaggerated exercise pressor response in patients with chronic kidney disease: a randomized controlled trial. Am J Physiol Renal Physiol 2016; 310:F1016-25. [PMID: 26962106 PMCID: PMC5002055 DOI: 10.1152/ajprenal.00527.2015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 02/28/2016] [Indexed: 11/22/2022] Open
Abstract
Chronic kidney disease (CKD) patients have an exaggerated increase in blood pressure (BP) during rhythmic handgrip exercise (RHG 20%) and static handgrip exercise (SHG 30%). Nitric oxide levels increase during exercise and help prevent excessive hypertension by both increasing vasodilation and reducing sympathetic nerve activity (SNA). Therefore, we hypothesized that tetrahydrobiopterin (BH4), an essential cofactor for nitric oxide synthase, would ameliorate the exaggerated exercise pressor response in CKD patients. In a randomized, double-blinded, placebo-controlled trial, we tested the effects of 12 wk of sapropterin dihydrochloride (6R-BH4; n = 18) versus placebo (n = 14) treatement on BP and muscle SNA (MSNA) responses during RHG 20% and SHG 30% in CKD patients. The 6R-BH4-treated group had a significantly lower systolic BP (+6 ± 1 vs. +13 ± 2 mmHg, P = 0.002) and mean arterial pressure response (+5 ± 1 vs. +10 ± 2 mmHg, P = 0.020) during RHG 20% and a significantly lower systolic BP response (+19 ± 3 vs. +28 ± 3 mmHg, P = 0.043) during SHG 30%. Under baseline conditions, there was no significant difference in MSNA responses between the groups; however, when the BP response during exercise was equalized between the groups using nitroprusside, the 6R-BH4-treated group had a significantly lower MSNA response during RHG 20% (6R-BH4 vs. placebo, +12 ± 1 vs. +21 ± 2 bursts/min, P = 0.004) but not during SHG 30%. These findings suggest that 6R-BH4 ameliorates the augmented BP response during RHG 20% and SHG 30% in CKD patients. A reduction in reflex activation of SNA may contribute to the decreased exercise pressor response during RHG 20% but not during SHG 30% in CKD patients.
Collapse
Affiliation(s)
- Ann M Lin
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Research Service Line, Department of Veterans Affairs Medical Center, Decatur, Georgia
| | - Peizhou Liao
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Erin C Millson
- Clinical Research Network, Atlanta Clinical and Translational Science Institute, Emory University School of Medicine, Atlanta, Georgia; and
| | - Arshed A Quyyumi
- Cardiology Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Jeanie Park
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Research Service Line, Department of Veterans Affairs Medical Center, Decatur, Georgia;
| |
Collapse
|
23
|
Matthews EL, Brian MS, Coyle DE, Edwards DG, Stocker SD, Wenner MM, Farquhar WB. Peripheral venous distension elicits a blood pressure raising reflex in young and middle-aged adults. Am J Physiol Regul Integr Comp Physiol 2016; 310:R1128-33. [PMID: 27053648 DOI: 10.1152/ajpregu.00438.2015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 03/31/2016] [Indexed: 11/22/2022]
Abstract
Distension of peripheral veins in humans elicits a pressor and sympathoexcitatory response that is mediated through group III/IV skeletal muscle afferents. There is some evidence that autonomic reflexes mediated by these sensory fibers are blunted with increasing age, yet to date the venous distension reflex has only been studied in young adults. Therefore, we tested the hypothesis that the venous distension reflex would be attenuated in middle-aged compared with young adults. Nineteen young (14 men/5 women, 25 ± 1 yr) and 13 middle-aged (9 men/4 women, 50 ± 2 yr) healthy normotensive participants underwent venous distension via saline infusion through a retrograde intravenous catheter in an antecubital vein during limb occlusion. Beat-by-beat blood pressure, muscle sympathetic nerve activity (MSNA), and model flow-derived cardiac output (Q), and total peripheral resistance (TPR) were recorded throughout the trial. Mean arterial pressure (MAP) increased during the venous distension in both young (baseline 83 ± 2, peak 94 ± 3 mmHg; P < 0.05) and middle-aged adults (baseline 88 ± 2, peak 103 ± 3 mmHg; P < 0.05). MSNA also increased in both groups [young: baseline 886 ± 143, peak 1,961 ± 242 arbitrary units (AU)/min; middle-aged: baseline 1,164 ± 225, peak 2,515 ± 404 AU/min; both P < 0.05]. TPR (P < 0.001), but not Q (P = 0.76), increased during the trial. However, the observed increases in blood pressure, MSNA, and TPR were similar between young and middle-aged adults. Additionally, no correlation was found between age and the response to venous distension (all P > 0.05). These findings suggest that peripheral venous distension elicits a pressor and sympathetic response in middle-aged adults similar to the response observed in young adults.
Collapse
Affiliation(s)
- Evan L Matthews
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware; and
| | - Michael S Brian
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware; and
| | - Dana E Coyle
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware; and
| | - David G Edwards
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware; and
| | - Sean D Stocker
- Departments of Physiology and Neural and Behavioral Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Megan M Wenner
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware; and
| | - William B Farquhar
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware; and
| |
Collapse
|
24
|
Mizuno M, Mitchell JH, Smith SA. The exercise pressor reflex in hypertension. THE JOURNAL OF PHYSICAL FITNESS AND SPORTS MEDICINE 2016. [DOI: 10.7600/jpfsm.5.339] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Masaki Mizuno
- Department of Health Care Sciences, University of Texas Southwestern Medical Center
- Internal Medicine, University of Texas Southwestern Medical Center
| | - Jere H. Mitchell
- Internal Medicine, University of Texas Southwestern Medical Center
| | - Scott A. Smith
- Department of Health Care Sciences, University of Texas Southwestern Medical Center
- Internal Medicine, University of Texas Southwestern Medical Center
| |
Collapse
|
25
|
Vieira PJC, Silva LR, Maldamer VZ, Cipriano G, Chiappa AMG, Schuster R, Boni VHF, Grandi T, Wolpat A, Roseguini BT, Chiappa GR. Skeletal muscle metaboreflex in patients with chronic renal failure. Clin Physiol Funct Imaging 2015; 37:229-234. [DOI: 10.1111/cpf.12293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 06/29/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Paulo J. C. Vieira
- Exercise Pathophysiology Research Laboratory; Hospital de Clinicas de Porto Alegre; Federal University of Rio Grande do Sul; Porto Alegre Brazil
| | - Leonardo R. Silva
- Physical Therapy Division; Serra Gaucha College and Public Health Research Group; Caxias do Sul Brazil
| | | | - Gerson Cipriano
- Physical Therapy Department; University of Brasilia; Brasilia Brazil
| | | | - Rodrigo Schuster
- Physical Therapy Division; Serra Gaucha College and Public Health Research Group; Caxias do Sul Brazil
| | | | - Tatiani Grandi
- Physical Therapy Division; Serra Gaucha College and Public Health Research Group; Caxias do Sul Brazil
| | - Andiara Wolpat
- Physical Therapy Division; Serra Gaucha College and Public Health Research Group; Caxias do Sul Brazil
| | - Bruno T. Roseguini
- Exercise Pathophysiology Research Laboratory; Hospital de Clinicas de Porto Alegre; Federal University of Rio Grande do Sul; Porto Alegre Brazil
| | - Gaspar R. Chiappa
- Exercise Pathophysiology Research Laboratory; Hospital de Clinicas de Porto Alegre; Federal University of Rio Grande do Sul; Porto Alegre Brazil
| |
Collapse
|
26
|
Abnormal neurocirculatory control during exercise in humans with chronic renal failure. Auton Neurosci 2014; 188:74-81. [PMID: 25458430 DOI: 10.1016/j.autneu.2014.10.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 09/13/2014] [Accepted: 10/13/2014] [Indexed: 02/07/2023]
Abstract
Abnormal neurocirculatory control during exercise is one important mechanism leading to exercise intolerance in patients with both end-stage renal disease (ESRD) and earlier stages of chronic kidney disease (CKD). This review will provide an overview of mechanisms underlying abnormal neurocirculatory and hemodynamic responses to exercise in patients with kidney disease. Recent studies have shown that ESRD and CKD patients have an exaggerated increase in blood pressure (BP) during both isometric and rhythmic exercise. Subsequent studies examining the role of the exercise pressor reflex in the augmented pressor response revealed that muscle sympathetic nerve activity (MSNA) was not augmented during exercise in these patients, and metaboreflex-mediated increases in MSNA were blunted, while mechanoreflex-mediated increases were preserved under basal conditions. However, normalizing the augmented BP response during exercise via infusion of nitroprusside (NTP), and thereby equalizing baroreflex-mediated suppression of MSNA, an important modulator of the final hemodynamic response to exercise, revealed that CKD patients had an exaggerated increase in MSNA during isometric and rhythmic exercise. In addition, mechanoreflex-mediated control was augmented, and metaboreceptor blunting was no longer apparent in CKD patients with baroreflex normalization. Factors leading to mechanoreceptor sensitization, and other mechanisms underlying the exaggerated exercise pressor response, such as impaired functional sympatholysis, should be investigated in future studies.
Collapse
|