Exercise in the end-stage renal disease population

Physical fitness is an independent predictor of chronic kidney disease development in apparently healthy individuals

BACKGROUND

The cardiovascular and metabolic benefits of physical activity have been studied at length, however, data on the association between physical fitness and progression to kidney disease is lacking. We aimed to identify the association between cardiorespiratory fitness and development of chronic kidney disease (CKD) among the healthy population.

METHODS

We retrospectively investigated 11,579 healthy self-referred subjects who underwent annual medical screening. All subjects had an estimated glomerular filtration rate (eGFR) above 60 ml/min/1.73 m2, no known kidney disease, hematuria or proteinuria, and were free of diabetes or cardiovascular disease at baseline. All participants completed a maximal exercise test, and were categorized into low and high cardiorespiratory fitness groups based on age- and gender-specific quintiles. The primary end point was the development of significant CKD defined as eGFR below 45 ml/min/1.73 m2 during follow-up.

RESULTS

Median follow-up was 7.6 years, and the participants' median age was 50 ± 8 years. Baseline creatinine and eGFR were 1.02 mg/dl and 81 ml/min/1.73 m2, respectively. During follow-up, 81 (0.6%) participants developed CKD, and the cumulative probability was significantly higher among the low fitness group (HR = 2.41, p = 0.001). The effect of physical fitness on the risk to develop CKD remained significant after adjusting for age, gender, baseline creatinine and other cardiovascular risk factors.

CONCLUSION

Cardiorespiratory fitness is an independent risk factor inversely associated with development of CKD.

Dependency and frailty in the older haemodialysis patient

BACKGROUND

Frailty among older adults undergoing hemodialysis is increasingly prevalent, significantly impacting cognitive function, mobility, and social engagement. This study focuses on the clinical profiles of very older adults in hemodialysis, particularly examining the interplay of dependency and frailty, and their influence on dialysis regimens.

METHODS

In this observational, descriptive study, 107 patients aged over 75 from four outpatient centers and one hospital unit were examined over a year. Patient data encompassed sociodemographic factors, dialysis specifics, analytical outcomes, lifestyle elements, and self-reported post-treatment fatigue. Malnutrition-inflammation scale was used to measure the Nutritional status; MIS scale for malnutrition-inflammation, Barthel index for dependency, Charlson comorbidity index; FRIED scale for frailty and the SF12 quality of life measure.

RESULTS

The study unveiled that a substantial number of older adults on hemodialysis faced malnutrition (55%), dependency (21%), frailty (46%), and diminished quality of life (57%). Patients with dependency were distinctively marked by higher comorbidity, severe malnutrition, enhanced frailty, nursing home residency, dependency on ambulance transportation, and significantly limited mobility, with 77% unable to walk. Notably, 56% of participants experienced considerable post-dialysis fatigue, correlating with higher comorbidity, increased dependency, and poorer quality of life. Despite varying clinical conditions, dialysis patterns were consistent across the patient cohort.

CONCLUSIONS

The older adult cohort, averaging over four years on hemodialysis, exhibited high rates of comorbidity, frailty, and dependency, necessitating substantial support in transport and living arrangements. A third of these patients lacked residual urine output, yet their dialysis regimen mirrored those with preserved output. The study underscores the imperative for tailored therapeutic strategies to mitigate dependency, preserve residual renal function, and alleviate post-dialysis fatigue, ultimately enhancing the physical quality of life for these patients.

Relevance of the Get Active Questionnaire for Pre-Participation Exercise Screening in the General Population in a Tropical Environment

The Get Active Questionnaire (GAQ), developed by the Canadian Society for Exercise Professionals (CSEP), was recently recommended for pre-participation screening of the general population in Singapore before increasing their exercise levels. This literature review examines the evidence behind the GAQ and its relevance to our tropical environment. Searches were carried out via Pubmed, MEDLINE and the Cochrane Central Register of Controlled Trials. Resources referenced by the CSEPs were hand searched. The CSEP was also contacted for further information. The evidence behind each GAQ question was compared to international literature and guidelines, where applicable. Out of 273 studies, 49 were suitable for analysis. Two GAQ studies commissioned by the CSEP showed a high negative predictive value but high false negative rate. Of the nine GAQ questions, those on dizziness, joint pains and chronic diseases appear to be justified. Those on heart disease/stroke, hypertension, breathlessness and concussion require modification. The one on syncope can be amalgamated into the dizziness question. The remaining question may be deleted. No long-term studies were available to validate the use of the GAQ. Heat disorders were not considered in the GAQ. Modification of the GAQ, including the inclusion of environmental factors, may make it more suitable for the general population and should be considered.

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

Rationale & Objective

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

Study Design

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

Setting & Participants

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

Analytical Approach

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

Results

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

Limitations

Participants geographically limited to Northern California.

Conclusions

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

Effect of Intradialytic Exercise on Cardiovascular Outcomes in Maintenance Hemodialysis: A Systematic Review and Meta-Analysis

Key Points

Individuals receiving hemodialysis have high rates of cardiovascular disease not explained by traditional cardiovascular risk factors. Intradialytic exercise improves cardiovascular outcomes, including arterial resistance, BP, and heart rate variability. Clinicians should consider including intradialytic aerobic exercise programs in hemodialysis care to supplement broader treatment plans.

Background

Cardiovascular disease is the leading cause of death among people with kidney failure on hemodialysis, for whom improving cardiovascular health is a research priority. Intradialytic myocardial stunning is common and associated with adverse cardiovascular events. Intradialytic exercise may mitigate intradialytic myocardial stunning and improve cardiovascular structure and function. This systematic review investigated the effect of intradialytic exercise on cardiovascular outcomes in adults undergoing maintenance hemodialysis (PROSPERO CRD42018103118).

Methods

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we systematically searched MEDLINE, Embase, Cochrane CENTRAL, SportDiscus, and PEDro databases from 1960 until June 2022, for randomized and nonrandomized studies investigating the effect of intradialytic exercise programs on objective cardiovascular outcomes, prespecified as primary or secondary outcomes. The primary outcome was arterial resistance.

Results

Of 10,837 references identified, 32 met eligibility criteria. These studies investigated the effect of intradialytic exercise on arterial resistance (eight studies), BP (20 studies), myocardial structure and function (seven studies), endothelial function (two studies), sympathetic overactivity (nine studies), biomarkers of cardiac injury (three studies), and cardiovascular hospitalization and mortality (two studies). Most studies used aerobic exercise as the intervention and usual care (no exercise) controls. Meta-analysis of intradialytic exercise versus usual care resulted in a statistically significant reduction in arterial resistance measured by pulse wave velocity with mean difference −1.63 m/s (95% confidence interval, −2.51 to −0.75). Meta-analyses for diastolic BP, left ventricular ejection fraction, and low-frequency/high-frequency ratio measure of heart rate variability also showed statistically significant improvements with exercise. There was no significant difference in change in systolic BP, augmentation index, and left ventricular mass index between groups.

Conclusions

Intradialytic exercise programming resulted in a clinically meaningful improvement to pulse wave velocity, a component of arterial resistance. Improvements in several physiologic measures of cardiovascular health, including diastolic BP, left ventricular ejection fraction, and heart rate variability measured by the low-frequency/high-frequency ratio were also observed. The effects of intradialytic exercise on major adverse cardiovascular events remains uncertain.

Renal Rehabilitation: Present and Future Perspectives

Chronic kidney disease (CKD) is a global health problem. In patients with CKD, exercise endurance is decreased, especially as renal dysfunction advances. This is due to the combined effects of protein-energy wasting, uremic acidosis, and inflammatory cachexia, which lead to sarcopenia and are aggravated by a sedentary lifestyle, resulting in a progressive downward spiral of deconditioning. Renal rehabilitation (RR) is a coordinated, multifaceted intervention designed to optimize a patient's physical, psychological, and social functioning, as well as to stabilize, slow, or even reverse the progression of renal deterioration, improving exercise tolerance and preventing the onset and worsening of heart failure, thereby reducing morbidity and mortality. This review focused on the history and benefits of RR in patients with CKD. Based on current evidence, RR is an effective, feasible, and safe secondary prevention strategy in CKD. RR is a promising model for a new field of rehabilitation. Therefore, efforts to increase RR implementation rates are urgently needed.

A Comprehensive Exercise (COMEX) Intervention to Optimize Exercise Participation for Improving Patient-Centered Outcomes and Physical Functioning in Patients Receiving Hemodialysis: Development and Pilot Testing

Rationale & Objective

To address the need for an intradialytic exercise program that is easily delivered in clinical setting, engaging and scalable, we developed a novel COMprehensive EXercise (COMEX) program based on input from patients receiving hemodialysis (HD), dialysis staff members and nephrologists. The objective of this study was to determine the feasibility, safety, and acceptance of COMEX during HD.

Study Design

Single-arm prospective pilot feasibility study.

Setting & Participants

Seventeen patients receiving in-center HD.

Intervention

Three-month participation in the COMEX program, which included video-based dialysis chair exercises (aerobic and resistance) integrated with educational and motivational components.

Outcomes

Data on recruitment, adherence, safety and acceptability were collected. Additional assessments were performed to evaluate changes in physical functioning, patient-reported symptoms, and objectively measured sleep and physical activity. We also examined the feasibility of obtaining skeletal muscle biopsies and blood samples to explore molecular mechanisms of muscle atrophy and to assess platelet mitochondrial function and adaptation to exercise during HD.

Results

Thirteen of the 17 (76%) participants completed the 3-month intervention. The mean participant age was 63.6 ± 15.1 years. In total, 46% of participants were males, and 55% were White. The mean body mass index was 38.7 ± 11.6 kg/m2. There were no reported adverse effects, and the adherence rate to exercise sessions was high with 88% of the sessions completed. Patient satisfaction was high, as 100% of the patients would recommend the program to other dialysis patients. It was feasible to collect data on physical functioning, patient-reported symptoms, and objective sleep and physical activity and to obtain muscle biopsies and blood samples.

Limitations

Small sample size, lack of an onsite exercise professional, and technological issues with telemedicine behavioral motivation.

Conclusions

The COMEX intradialytic exercise intervention is safe and acceptable to patients, and outcome measures were feasible to obtain. Future studies should consider including exercise professionals to facilitate progression through a personalized exercise protocol.

Funding Source

This work is supported by pilot award from P30 DK079307 (PI, Jhamb).

Trial Registration

ClinicalTrials.gov, NCT03055299.

Plain-Language Summary

We tested a new COMprehensive EXercise (COMEX) program to deliver exercise during dialysis. This 3-month program included video-based dialysis chair exercises (aerobic and resistance) integrated with educational and motivational components. Our study shows COMEX was feasible, had high satisfaction and adherence, and was safe. It was feasible to collect data on physical functioning, patient-reported symptoms, and objective sleep and physical activity and to obtain muscle biopsies and blood samples. Future studies should consider including exercise professionals to facilitate progression through a personalized exercise protocol.

Physical activity can influence the relationship between ethylene oxide and risk of kidney stones: A cross-sectional study from the NHANES 2013-2016

Ethylene oxide (EO) is known to cause inflammatory damage, and suitable physical activity can reportedly affect the risk of kidney stones. In this study, we aimed to investigate the relationship between EO and kidney stones and whether physical activity can potentially influence the relationship between EO and kidney stones. Overall, 3,336 adult participants were included; of them, 330 (9.9%) had a self-reported history of kidney stones. Data were obtained from the National Health and Nutrition Examination Survey 2013-2016. Physical activity was calculated using metabolic equivalent, weekly frequency, and duration. Logistic regression and restricted cubic spline (RCS) curves were used to explore the association between physical activity, EO, and kidney stones. Dose-response curves from the RCS showed a nonlinear positive association between EO and kidney stones. Multivariate logistic regression analysis revealed an adjusted odds ratio (aOR) of 1.548 (95% confidence interval 1.123-2.135, P = 0.008) for the risk of kidney stones among participants in the highest quartile (Q4) group compared with those in the lowest quartile (Q1) group. Furthermore, compared to the Q1 group, the aOR for risk of kidney stones in the Q4 group was 1.326 in participants without physical activity, a decreased risk (aOR 1.239) in participants with low physical activity, and an increased risk (aOR 1.981) in those with high physical activity. This study suggests that EO is a risk factor for kidney stones and that suitable physical activity may moderate this relationship to some extent; however, excessive physical activity can exacerbate this relationship.

The value of cardiopulmonary exercise testing and stress echocardiography in the prediction of all-cause mortality in adults with end-stage renal disease

We aimed to assess the prognostic utility of different parameters routinely assessed from cardiopulmonary exercise testing (CPET) and exercise echocardiography in adults with end-stage renal disease (ESRD). Forty-two ESRD (37 male) individuals (age: 58 ± 13 years, height: 169.30 ± 8.30 cm, weight: 81 ± 15 kg, body surface area: 1.92 ± 0.20 m²) underwent a maximal/symptom limited CPET, with a full cross-sectional echocardiogram performed at baseline and peak exercise. All participants were prospectively followed over a 10-year period, with all-cause mortality as the primary endpoint. After the follow-up period, a total of 19 participants (45%) died. Left atrial size (4.70 ± 0.70 vs. 3.65 ± 0.50 cm, P < 0.001) and anteroseptal wall thickness (1.28 ± 0.40 vs. 1.06 ± 0.02 cm, P = 0.002) were significantly greater in those that died, while peak heart rate was significantly lower (108 ± 12 vs. 128 ± 14 bpm, P < 0.001). The prevalence of myocardial ischaemia (13 vs. 8 participants, P = 0.03) was significantly greater, while peak VO₂ (9.80 ± 2.10 vs. 15.90 ± 4.30 ml·kg^-1·min^-1, P < 0.001) was significantly lower in those that died. Following multivariate cox regression, myocardial ischaemia (Hazard Ratio 3.08; 95% Confidence Interval 1.09-8.70; P = 0.03) and peak VO₂ (HR 0.73; 95% CI 0.64-0.84; P < 0.001) were significant independent predictors of 10-year all-cause mortality. This is the first study to establish peak VO₂ as powerful marker of all-cause mortality when assessed with clinical, resting and stress echocardiography parameters in people with ESRD over a 10-year follow up period. This observation indicates that, in clinical practice, CPET and exercise echocardiography may serve as valuable tools for the risk stratification of individuals with ESRD. HIGHLIGHTSWe aimed to assess the prognostic utility of cardiopulmonary exercise testing (CPET) and exercise echocardiography in end-stage renal disease (ESRD) with 10-year mortality.Peak aerobic capacity and the presence of ischaemic heart disease were independently associated with all-cause mortality.This observation indicates that, in clinical practice, CPET and exercise echocardiography may serve as valuable tools for the risk stratification of individuals with end-stage renal disease.

Physical function management for elderly dialysis patients: prevention and improvement of frailty and disability

Frailty has become an emerging public health problem in the aging society and is regarded as a state of vulnerability to developing increased dependency and/or mortality when exposed to a stressor. As the proportion of elderly dialysis patients is increasing worldwide, frailty has recently influenced on the clinical outcomes among those patients also caused great attention. The prevalence of frailty among dialysis patients has ranged from 3.0- to 10-fold higher than in community-dwelling elderly. Since frailty has been found to be associated with higher mortality, independent of clinical characteristics and comorbidity, interventions to improve frailty have the potential to contribute to better quality of life and lower mortality among dialysis patients. Moreover, clinical research should be focused on the possibility that early rehabilitation of dialysis patients might improve poor outcomes. Current clinical question should aim to take an appropriate strategy to address frailty, including identifying the optimal timing for intervention.

Importance of physical exercise prescription in patients with chronic kidney disease: results of the survey of the Grupo Español Multidisciplinar de Ejercicio Físico en el Enfermo Renal [Spanish Multidisciplinary Group of Physical Exercise in Kidney Patients] (GEMEFER)

INTRODUCTION

Despite the benefits of physical exercise (PE) for patients with chronic kidney disease (CKD), the number of Nephrology services that have PE programs is limited.

OBJECTIVES

To describe the degree of knowledge of PE benefits in patients with CKD among professionals, as well as the level of implementation and characteristics of PE programs in Nephrology services in Spain.

METHODS

A questionnaire on the degree of knowledge and prescription of PE in patients with CKD was designed and sent to members of the Spanish Nephrology and Nephrology Nursing Societies, as well as to physiotherapists and professionals in the Sciences of Physical Activity and Sport (PASS).

RESULTS

264 professionals participated. 98.8% agreed on the importance of prescribing PE, but only 20.5% carry out an assessment of functional capacity and 19.3% have a PE program for patients with CKD in their centre. The most frequent programs are performed for haemodialysis patients and strength and aerobic resistance exercises are combined. A physiotherapist or a PASS usually participates in its prescription. The main barriers were the absence of human and/or physical resources and the lack of training.

CONCLUSIONS

Healthcare workers know the benefits of PE in patients with CKD. However, the implementation of these programs in Spain is low, motivated by the lack of resources and training of professionals. We must establish strategies to guarantee an adequate functional capacity within the care of our patients.

Effect of intradialytic exercises (IDE) on maximal oxygen consumption and quality of life undergoing hemodialysis in Indian population—a pilot study

Background

End stage renal disease (ESRD) is emerging as a major health issues across developing countries with limited access and awareness about the importance of exercises in daily life. People on prolong hemodialysis has difficulty in performing their activities of daily living (ADL). Loss of muscle mass is inevitable among patients on hemodialysis that leads to morbidity and mortality. Exercise is feasible during dialysis and can enhance quality of life. Increase in aerobic endurance by various combined protocol of aerobic and resistive exercises can improve compliance to regular exercise that underlines the theme of present study.

Methods

A total of 31 participants were recruited during November 2019 to February 2020, after screening of 65 participants for selection criteria from Indraprastha Apollo Hospital’s dialysis unit. The average age of the participants was 52.36 ± 11.56 years. A single-blinded, pre-test–post-test quasi-experimental clinical trial for intradialytic exercise program involving lower limb ergometer and resistance training for lower limbs and non-fistula hand for 24 sessions, in 3 months, twice a week was conducted.

Results

The exercise program was well tolerated and all patients completed it. Aerobic and resistance intradialytic exercises (IDE) had a positive effect on maximal oxygen consumption (VO2 Max), quality of life (SF 36), and sleep quality (PSQI). IDE showed statistically significant difference from pre- to post-intervention for maximal oxygen consumption, quality of life boosting their sleep quality.

Conclusions

IDE found to benefit the patient and results showed a significant improvement in maximal oxygen consumption, sleep quality, quality of life and fatigue over a span of 12 weeks.

Trial registration

CTRI, CTRI/2019/08/020848. Registered on 22 August 2019.

Utility of geriatric assessments in evaluation of older adults for kidney transplantation

BACKGROUND

While kidney transplantation has favorable outcomes in patients aged 65 years and older, many are not referred for evaluation despite having no contraindications. We wanted to determine whether incorporating geriatrics and geriatric assessments (GA), as part of kidney transplant evaluation at the University of Chicago Medicine, would help identify suitable candidates and improve transplantation outcomes among older adults.

METHODS

Between 2012 and 2016, as part of their multi-disciplinary transplant evaluation, 171 patients underwent an initial GA with the study geriatrician, who rated them on a five-point scale from "poor" to "excellent," and presented their cases to multidisciplinary transplant review meetings. Patients were followed until June 1st, 2021. Predictor variables included geriatric recommendation, clinical characteristics, and demographics. Outcomes of interest were mortality, receipt of transplant, and waitlist placement.

RESULTS

Compared to patients rated "poor," "marginal," or "fair," we found that patients that the geriatrician recommended as "good" or "excellent" were more likely to be waitlisted and receive a transplant. Favorably rated patients were also less likely to be removed from the waitlist due to becoming medically unfit, meaning worsening medical morbidity, frailty, and cognitive status.

CONCLUSION

Including geriatricians to perform GAs as part of the transplant evaluation process can help identify suitable elderly candidates.

Physical exercise and cognitive training interventions to improve cognition in hemodialysis patients: A systematic review

Introduction

Patients with chronic kidney disease treated with hemodialysis (HD) have lower cognitive abilities compared to the age-matched healthy population. Recently, physical exercise and cognitive training have been presented as possible interventions to improve cognitive abilities both in the general population and in patients with chronic diseases. To date, there is no general overview of the current knowledge on how these interventions affect cognitive abilities in HD patients and what tests are used to measure these effects.

Methods

Three electronic databases were searched for randomized controlled studies of physical exercise or cognitive training interventions that examined effects on cognitive abilities/performance in HD patients.

Results

Six articles were included. All included studies used physical exercise as an intervention, with one study also including tablet-based cognitive training. Four studies included an intradialytic approach and two included a home-based intervention. Intervention lasted. A significant intervention effect was observed in three studies compared with the control condition.

Conclusion

The present review suggests that physical exercise might improve or at least not worsen cognitive performance in HD patients, whereas the effect of cognitive training has not yet been adequately studied. There is a need for more sensitive and specific cognitive tests to adequately measure the effects of interventions in the HD population.

Palliative rehabilitation in end-stage renal failure

Background

In end-stage chronic kidney disease (CKD), patients experience disabilities stemming from organ failure. These can be worsened by symptoms and complications of underlying cause(s), and the conditions associated with the CKD. There is a dearth of literature regarding palliative rehabilitation in end-stage CKD. Our case highlights the complex medical and rehabilitative issues that such patients face.

Case presentation

A 64-year-old male had end-stage CKD and declined dialysis. After sustaining a myocardial infarction, he suffered a posterior circulation stroke the following month. Whilst undergoing stroke rehabilitation, his progress was further hampered by symptoms of kidney failure. The patient underwent interdisciplinary rehabilitation for 29 days. Goal-setting was performed with the patient and family to allow contextualization to the patient’s stage of disease, beliefs and environment. Care-giver training was provided to facilitate discharge back home. He demonstrated improvements in physical endurance and function. His Functional Independence Measure score improved from 51 to 82. He outlived his prognosis of 3–6 months and demised 15 months after discharge.

Conclusions

In end-stage CKD without renal replacement therapy, rehabilitation and palliative care efforts align to enhance quality of life, in the face of unlikely cure. While palliative care provides symptom management and supportive care, rehabilitation safeguards physical endurance and ability. It is in the hope of doing so, independence and thence, self-esteem, can be maintained. Future research should explore the benefits of palliative rehabilitation in renal failure.

Associations of Physical Activity, Kidney Function, Diet, and Inflammatory Markers in High-Risk Type-2 Diabetes With Early-Stage Chronic Kidney Disease (CKD)

OBJECTIVES Quantitative information and associations of physical activity, kidney function, diet, and inflammation are dearth in high-risk diabetes. Yet could delay type-2 diabetes, late-stage chronic kidney disease (CKD) and could be useful in designing effective interventions. The study aims to quantify the associations of physical activity, kidney function, diet and inflammation in adults with high-risk type-2 diabetes (and early CKD) recruited to a lifestyle education programme.METHODS Baseline, 12-month dietary, accelerometery, and circulating inflammatory markers, Interleukin-6 (IL-6) and C-reactive protein (CRP) data were assessed from 159 (104 male) high-risk diabetes with stage 2 CKD (mean (SD) estimated glomerular filteration rate (eGFR); 77.5(7.6) ml/min/1.73m2, age; 66(6) years, BMI; 31.8(4.2) kg/m2) who were recruited to a lifestyle education programme. Linear regression examined the effects and associations of the outcome measures.RESULTS eGFR decreased by -2.0 (1.7) ml/min/1.73 m2 (P = 0.04) after 12-months, but mean daily steps, moderate to vigorous physical activity (MVPA) levels, intakes of fibre, total and unsaturated fat, and circulating IL-6 and CRP did not change. However, inter-individual responses were highly variable. eGFR correlated positively with baseline IL-6 (r = 0.17, P = 0.02). Unadjusted, there were no associations between change in eGFR (12_0) and change in any of the activity, inflammatory or dietary outcomes. However, the regression models of these outcomes for change in eGFR (12_0) became significant with multiple covariates.CONCLUSION A combination of healthy lifestyle behaviours should be encouraged for a positive effect on future kidney function.

Implementing a resistance training programme for patients on short daily haemodialysis: A feasibility study

BACKGROUND

Kidney failure patients receiving haemodialysis experience protein-energy wasting, muscle mass loss and physical function impairment. Intradialytic exercise interventions seem to modify these features, but they are often not implemented as a clinical routine.

OBJECTIVE

To investigate the feasibility of implementing a supervised intradialytic resistance training programme as a clinical routine for patients receiving short daily haemodialysis.

DESIGN

A prospective longitudinal study.

PARTICIPANTS

Eighteen patients in a supervised intradialytic resistance training programme for 8 months.

MEASUREMENTS

It consisted of a warm-up, lower- and upper-limb resistance exercises and a cool-down. Patients performed the resistance training during the first half of haemodialysis, twice a week, supervised by exercise physiologists and physiotherapists. The feasibility was assessed by the total and partial adherences, the reasons for refusing or for not exercising and the intradialytic complications.

RESULTS

From a total of 953 potential exercise sessions, 759 were performed, with a 79.6% adherence rate. In the first 9 weeks, the adherence rate was 86.6% and the lowest rate was in the 19-27 weeks (73.5%). The main intradialytic complication during exercise sessions was hypotension (n = 31; 4.1%). The highest number of complications was reported during the first 9 weeks (n = 27; 9.1%). The main reasons for refusing or for not performing the intradialytic exercise sessions were clinical complications previous to exercise time (n = 63; 32.5%) and self-reported indisposition (n = 62; 32.0%).

CONCLUSIONS

The intradialytic resistance training programme, supervised by exercise physiologists and physiotherapists, had very low complications, achieved a high long-term adherence rate and showed to be feasible as a clinical routine for patients receiving short daily haemodialysis.

Exercise-Based Renal Rehabilitation: A Bibliometric Analysis From 1969 to 2021

Chronic kidney disease (CKD) is a growing global health challenge with an increasing incidence rate. Exercise-based renal rehabilitation is an evidence-based, multidisciplinary, and comprehensive intervention designed to improve the physical and psychological condition of patients with CKD. The knowledge structure, research hotspots, and development trends in exercise-based renal rehabilitation have not been systematically described. The aim of this study was to provide a bibliometric perspective of the progress in this field. Publications about exercise-based renal rehabilitation were retrieved from the Web of Science Core Collection, using the terms "exercise," "physical activity," and "chronic kidney disease." Annual publications, subject categories, countries, authors, references, and keywords in this field were visually analyzed using the Citespace, VOSview, and Excel software. A total of 4,610 publications were analyzed, with a steady increase in publications in the field. Overall, the United States is the major contributor to the study of exercise-based renal rehabilitation. Johansen KL and Painter P are the key researchers in this field. Keyword analysis shows that research hotspots in this field include exercise/physical activity for different stages of CKD, exercise-based renal rehabilitation for frailty, and physical activity management for CKD. These findings will make understanding exercise-based renal rehabilitation research better and inform about future research ideas.

A pilot randomised controlled trial of an energy management programme for adults on maintenance haemodialysis: the fatigue-HD study

BACKGROUND

Identifying interventions to reduce fatigue and improve life participation are top research priorities of people on maintenance haemodialysis.

OBJECTIVE

Our primary objective was to explore the feasibility of conducting a randomised controlled trial of an energy management programme for people on maintenance haemodialysis.

DESIGN

Parallel-arm, 1:1, blinded, pilot randomised controlled trial.

PARTICIPANTS

Participants were recruited from 6 dialysis units in Calgary, Canada. Eligible patients were on maintenance haemodialysis, clinically stable and reported disabling fatigue on the Fatigue Severity Scale items 5, 7, 8 and 9.

RANDOMISATION

Participants were randomised using a computer-generated random number sequence according to permuted blocked randomisation, stratified by dialysis unit.

BLINDING

Participants were blinded to treatment allocation.

INTERVENTIONS

Participants received an attention control (general disease self-management education) or the Personal Energy Planning (PEP) programme, a tailored, web-supported 7-9 weeks energy management programme.

OUTCOMES

Eligibility, recruitment and attrition rates were recorded, and standardised intervention effects (Hedge's G) were calculated for fatigue and life participation questionnaires at one1-week postintervention and 12-week postintervention.

RESULTS

159 of 253 screened patients were eligible to be approached. 42 (26%) had fatigue, were interested and consented to participate, of whom 30 met eligibility criteria and were randomised (mean age 62.4 years (±14.7), 60% male). 22 enrolled participants (73%) completed all study procedures. Medium-sized intervention effects were observed on the Canadian Occupational Performance Measure (COPM)-Performance Scale, Global Life Participation Scale and Global Life Participation Satisfaction Scale at 1-week postintervention follow-up, compared with control. At 12-week follow-up, large and very large intervention effects were observed on the COPM-Performance Scale and COPM-Satisfaction Scale, respectively.

CONCLUSION

It is feasible to enrol and follow patients on haemodialysis in a randomised controlled trial of an energy management intervention. As the intervention was associated with improved life participation on some measures, a larger trial is justified.

Is health-related quality of life associated with adequacy of hemodialysis in chronic kidney disease patients?

INTRODUCTION

Monitoring Health Related Quality of Life (HRQoL) in different stages of chronic kidney disease is advised by all nephrology societies. We aimed to study the relation between quality of life and dialysis adequacy.

METHODS

One hundred patients (51% males), on regular hemodialysis 3/week for > 6 months in two hospitals were included. Single pool Kt/V was used to assess dialysis adequacy. Patients were grouped into 3 divisions according to Kt/v: Group A > 1.5 (n = 24), group B 1.2-1.5 (n = 54) and group C < 1.2 (n = 22). KDQOL-SF™ questionnaire was used to study quality of life in our groups. Group C was reassessed after 3 months of improving Kt/v.

RESULTS

Mean values were: Kt/V (1.48 ± 0.41), Cognitive Function (84.27 ± 9.96), Work status (30.00 ± 33.33), Energy (45.70 ± 13.89), Physical Function and Role limitations due to physical function (45.30 ± 12.39 and 31.25 ± 19.26, respectively). Group A had significantly higher scores of KDQOL-SF except Role limitations due to Physical Function. All subscales improved in group C after Kt/v improvement except 3 subscales, namely, work status, patient satisfaction and role limitation due to physical and emotional functions.

CONCLUSION

Inadequate HD badly affects quality of life and improving adequacy refines many components of quality of life.

Impact and safety outcomes of an intradialytic physical exercise program

INTRODUCTION

Patients undergoing hemodialysis (HD) are characterized by a poor physical condition and a substantial sedentary profile. The implementation of physical exercise programs in the hemodialysis units is usually limited by the inherent safeness and the lack of appropriate resources.

OBJECTIVES

We aimed to evaluate the impact and safety outcomes of the implementation of an intradialytic physical exercise program (IPE) by a multidisciplinary team (physiotherapist and nursing assistant) in the physical condition of the patients.

MATERIAL AND METHODS

This six months single-centre and experimental pre-post prospective study was carried out in 34 patients. A two day-week combined IPE intervention was implemented. The cardiopulmonary capacity (6MWT), muscular strength (HG, leg dynamometry and 10STS), body composition (bioimpedance) and coordination capacity (Timed Up and Go test) was assessed at the beginning and at the end of the study. Safety was evaluated by means of the number of issues regarding the vascular access, the hemodynamic stability as well as the vascular refilling profile (RBV) in each session. The adhesion to the program was also registered. Additionally, analytical parameters were recorded.

RESULTS

The adhesion to an IPE program was high (70.8%). A significant improvement of the cardiopulmonary capacity (6MWT average increase 47 m; p < 0.001), superior limbs (HG average increase of 1.6 kg; p = 0.007) as well as the lower extremities (10STS; p = 0.003; dynamometry p < 0.05). Regarding safeness, there were no incidences neither significant difference in the RBV.

CONCLUSIONS

A combined IPE may contribute to the improvement of the physical condition of the patients as well as ensures a safe development of the HD treatment. We suggest a multidisciplinary team in order to efficiently establish an IPE program.

Feasibility of long-term intradialytic exercise for older patients receiving hemodialysis: a retrospective single-center study

PURPOSE

Decreased physical function and physical activity are associated with adverse outcomes among patients undergoing hemodialysis (HD). Although intradialytic exercise (IDEx) can help improve physical function, few studies have evaluated whether long-term IDEx could improve physical function or physical activity in older HD patients. This study aimed to investigate the effects of intradialytic exercise (IDEx) on physical function and physical activity in older HD patients over a 24-month period.

METHODS

This retrospective study included clinically stable Japanese HD patients (aged ≥ 60 years) who visited our outpatient clinic. The patients were categorized into the IDEx (underwent IDEx) and non-IDEx (did not undergo IDEx) groups. The IDEx group underwent a 30-40 min low-intensity resistance training for three times/week during the HD period. Baseline, 12-month, and 24-month follow-up assessments were conducted to assess patient characteristics, physical function, and physical activity. Results were compared using generalized estimating equations.

RESULTS

The study included 57 patients with complete follow-up data. Baseline, 12-month, and 24-month follow-up assessments revealed no significant inter-group differences concerning physical function, physical activity, and other measurements.

CONCLUSION

IDEx was shown to have limited effect on physical function and physical activity among older HD patients in a clinical setting. Future studies are needed to re-evaluate IDEx programs in HD patients by incorporating exercises performed before and after the HD session.

Uremic toxins levels from the gut microbiota seem not to be altered by physical exercise in hemodialysis patients

PURPOSE

Regular physical exercise may result in many benefits to patients with chronic kidney disease (CKD) on hemodialysis (HD), including gut microbiota modulation and solute removal. The study aimed to evaluate the effects of two programs of intradialytic exercises on uremic toxins plasma levels in HD patients.

METHODS

In experiment 1, twenty HD patients [12 men, 44.1 ± 8.9 years, BMI of 23.4 ± 2.4 kg/m²] were randomized into two groups: Aerobic exercise group (AEG, n = 11) that performed aerobic exercise on an adapted exercise bike three times a week for three months (36 sessions) and Control group (CG, n = 9). In experiment 2, twenty-six HD patients [19 men, 47.6 ± 11.0 years, BMI of 25.9 ± 3.6 kg/m²] were randomized into Resistance exercise group (REG, n = 14) that performed a resistance exercise program (using elastic bands and ankle cuffs with both lower limbs) monitored three times a week, during six months (72 sessions) and CG (n = 12). P-cresyl sulfate (p-CS), indoxyl sulfate (IS), and indol-3-acetic acid (IAA) plasma levels were determined by high-performance liquid chromatography (HPLC) with fluorescent detection.

RESULTS

The uremic toxins plasma levels did not reduce in both exercise programs, aerobic exercise (IS: 32.7 ± 14.0 vs 33.0 ± 15.4 mg/L, p = 0.86; p-CS: 59.9 ± 39.3 vs 60.0 ± 41.2 mg/L, p = 0.99; IAA: 2233 [1488-2848] vs 2227 [1275-2824] µg/L, p = 0.72) and resistance exercise (IS: 28.3 ± 11.3 vs 29.1 ± 9.7 mg/L, p = 0.77; p-CS: 31.4 ± 21.3 vs 34.2 ± 19.8 mg/L, p = 0.63; IAA: 1628 [1330-3530] vs 2000 [971-3085] µg/L, p = 0.35) in HD patients.

CONCLUSION

According to our findings, physical exercise does not appear to alter the levels of uremic toxins produced by the gut microbiota in HD patients.

Chronic kidney disease: prevalence and association with handgrip strength in a cross-sectional study

Background

Poor physical function is strongly associated with mortality and poor clinical outcomes in adults with chronic kidney disease (CKD). Handgrip strength (HGS) is an important index for physical function in the general population, and the association between HGS and CKD is worth investigating.

Methods

From September to November 2015, we conducted a cross-sectional study consisting of 10,407 participants in Jurong City, China. Age-related and sex-specific HGS percentile curves were constructed using the GAMLSS method. In addition, logistic regression was applied to estimate the association between HGS and the presence of CKD with odds ratios (ORs) and 95 % confidence intervals (CIs).

Results

Participants with low HGS tended to be older and were more likely to have CKD (8.73 %). Smoothed centile curves of HGS showed a similar shape in both sexes: participants peaked at approximately 20–35 years old and gradually decreased after the age of 50. In addition, independent of age and other factors, the decreased presence of CKD was significantly identified in individuals with moderate (OR: 0.64, 95 % CI: 0.49–0.83) and high HGS (OR: 0.37, 95 % CI: 0.23–0.58).

Conclusions

We concluded that HGS was significantly negatively associated with CKD in Chinese community-dwelling persons.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02452-5.

Seven months of aerobic intradialytic exercise training can prevent muscle loss in haemodialysis patients: an ultrasonography study

PURPOSE

This study aimed to evaluate the effects of 7-month intradialytic exercise training (IDE) on vastus lateralis (VL) muscle architecture, functional capacity and quality of life in stable haemodialysis (HD) patients.

METHODS

44 HD patients were randomly assigned into an Exercise Group (EG = 21), which they received 7 months of IET, at 60% of pre-assessed maximum aerobic power, 3/week) or into a Control Group (CG = 23, no exercise). VL architecture was evaluated with ultrasonography, functional capacity was assessed using a series of functional tests (6 min walking test, 5 repetitions sit-to-stand, sit-to-stand 60 s, handgrip strength), and maximal aerobic power determined with a modified version of the Åstrand test. Quality of life and fatigue levels were evaluated using validated questionnaires.

RESULTS

VL fascicle angle and length did not change significantly in both groups (P > 0.05). Muscle thickness decreased in CG (P = 0.02) while it was fully preserved in the EG. Functional capacity increased only in the EG (6 min walking test 15.79 ± 12.35%, P < 0.001; max aerobic power 26.36 ± 1.24%, P < 0.001; STS-60rep: 10.23 ± 1.60%, P < 0.000; hand grip strength: 5.14 ± 28.30%, P < 0.02).

CONCLUSION

Intradialytic aerobic exercise training, improves functional capacity and prevents thigh muscle mass loss in HD patients. It is evident that muscle ultrasonography could play a pivotal role in assessing muscle quality changes in haemodialysis patients. A higher level of training intensity or combination with resistance exercises may be required to further improve anabolism and influence muscle architecture in this patient population.

CLINICAL TRIAL REGISTRY NUMBER

NCT03905551.

A systematic review of trials investigating the efficacy of exercise training for functional capacity and quality of life in chronic kidney disease patients

OBJECTIVE

To investigate the efficacy of exercise training on functional capacity and quality of life in chronic kidney disease.

DATA SOURCES

SCOPUS, CINAHL, Science Direct, Web of Science, MEDLINE, ProQuest, Physiotherapy Evidence Database (PEDRO), and Google Scholar databases were searched between 2010 and December 2020.

METHODS

Randomized controlled trials were included if they involved any types of exercise training (aerobic, resisted and respiratory ex.) conducted with chronic kidney disease patients. Three authors independently screened articles, extracted data, and assessed the methodological quality using PEDro scale, and two authors released any confliction. Modified Sackett Scale was used to determine the level of evidence for each outcome.

RESULTS

Out of 130 papers screened, 13 studies with 619 participants met the inclusion criteria. The frequency of the treatment ranged from three to four sessions per week for a period ranging from 8 to 24 weeks. According to the Pedro scale, the quality of studies ranged from good (three studies) to fair (ten studies). All included studies showed positive effects on the measured outcomes (functional capacity and quality of life in chronic kidney disease).

CONCLUSION

Exercise programs for chronic kidney disease patients provide beneficial clinical outcomes and optimize functional capacity and quality of life in those patients. Future studies still need to focus on high-quality evidence and studies evaluating the adverse effects of exercise.

Association of Cognitive Function Screening Results with Adherence and Performance in a Pedometer-Based Intervention

INTRODUCTION

A randomized, controlled trial of a pedometer-based walking intervention with weekly activity goals led to increased walking among dialysis patients. We examined whether impairment per cognitive function screening is associated with adherence and performance in the intervention.

METHODS

Thirty dialysis patients were randomly assigned to a 3-month pedometer-based intervention with weekly goals. Participants were administered the Telephone Interview of Cognitive Status (TICS), a test of global mental status. We examined the association of levels of impairment on the TICS (≥33: unimpaired, 26-32: ambiguous impairment, 21-25: mild cognitive impairment [MCI]) with adherence, achieving weekly goals, and increasing steps, physical performance (Short Physical Performance Battery, SPPB), and self-reported physical function (PF) through multivariable linear mixed-model and logistic regression analyses adjusted for age, sex, BMI, dialysis modality, baseline steps, baseline SPPB, and stroke status.

RESULTS

One-third of participants were unimpaired, and 13% had MCI. Participants with worse results on cognitive function screening missed more calls and completed fewer weekly goals than participants with better results. During the intervention, a worse result on cognitive function screening was associated with smaller increases in steps compared to those without impairment: (ambiguous: -620 [95% CI -174, -1,415], MCI: -1,653 [95% CI -120, -3,187]); less improvement in SPPB (ambiguous: -0.22 points [95% CI -0.08, -0.44], MCI: -0.45 [95% CI -0.13, -0.77]); and less improvement in PF (ambiguous: -4.0 points [95% CI -12.2, 4.1], MCI: -14.0 [95% CI -24.9, -3.1]). During the postintervention period, a worse result on cognitive function screening was associated with smaller increases in SPPB (ambiguous: -0.54 [95% CI -1.27, 0.19], MCI: -0.97 [95% CI -0.37, -1.58]) and PF (ambiguous: -3.3 [95% CI -6.5, -0.04], MCI: -10.5 [95% CI -18.7, -2.3]).

DISCUSSION/CONCLUSION

Participants with worse results on cognitive function screening had worse adherence and derived less benefit from this pedometer-based intervention. Future exercise interventions should be developed incorporating methods to address cognitive impairment, for example, by including caregivers when planning such interventions.

Impact and safety outcomes of an intradialytic physical exercise program

INTRODUCTION

Patients undergoing hemodialysis (HD) are characterized by a poor physical condition and a substantial sedentary profile. The implementation of physical exercise programs in the hemodialysis units is usually limited by the inherent safeness and the lack of appropriate resources.

OBJECTIVES

We aimed to evaluate the impact and safety outcomes of the implementation of an intradialytic physical exercise program (IPE) by a multidisciplinary team (physiotherapist and nursing assistant) in the physical condition of the patients.

MATERIAL AND METHODS

This six months single-centre and experimental pre-post prospective study was carried out in 34 patients. A two day-week combined IPE intervention was implemented. The cardiopulmonary capacity (6MWT), muscular strength (HG, leg dynamometry and 10STS), body composition (bioimpedance) and coordination capacity (Timed Up and Go test) was assessed at the beginning and at the end of the study. Safety was evaluated by means of the number of issues regarding the vascular access, the hemodynamic stability as well as the vascular refilling profile (RBV) in each session. The adhesion to the program was also registered. Additionally, analytical parameters were recorded.

RESULTS

The adhesion to an IPE program was high (70.8%). A significant improvement of the cardiopulmonary capacity (6MWT average increase 47m; p<0.001), superior limbs (HG average increase of 1.6kg; p=0.007) as well as the lower extremities (10STS; p=0.003; dynamometry p<0.05). Regarding safeness, there were no incidences neither significant difference in the RBV.

CONCLUSIONS

A combined IPE may contribute to the improvement of the physical condition of the patients as well as ensures a safe development of the HD treatment. We suggest a multidisciplinary team in order to efficiently establish an IPE program.

The Association Between Estimated Glomerular Filtration Rate and Hospitalization for Fatigue: A Population-Based Cohort Study

Background:

Fatigue is a pervasive symptom among patients with chronic kidney disease (CKD) that is associated with several adverse outcomes, but the incidence of hospitalization for fatigue is unknown.

Objective:

To explore the association between estimated glomerular filtration rate (eGFR) and incidence of hospitalization for fatigue.

Design:

Population-based retrospective cohort study using a provincial administrative dataset.

Setting:

Alberta, Canada.

Patients:

People above age 18 who had at least 1 outpatient serum creatinine measurement taken in Alberta between January 1, 2009, and December 31, 2016.

Measurements:

The first outpatient serum creatinine was used to estimate GFR. Hospitalization for fatigue was identified using International Classification of Diseases, Tenth Revision (ICD-10) code R53.x.

Methods:

Patients were stratified by CKD category based on their index eGFR. We used negative binomial regression to determine if there was an increased incidence of hospitalization for fatigue by declining kidney function (reference eGFR ≥ 60 mL/min/1.73m²). Estimates were stratified by age, and adjusted for age, sex, socioeconomic status, and comorbidity.

Results:

The study cohort consisted of 2 823 270 adults, with a mean age of 46.1 years and median follow-up duration of 6.0 years; 5 422 hospitalizations for fatigue occurred over 14 703 914 person-years of follow-up. Adjusted rates of hospitalization for fatigue increased with decreasing kidney function, across all age strata. The highest rates were seen in adults on dialysis (adjusted incident rate ratios 24.47, 6.66, and 3.13 for those aged 18 to 64, 65 to 74, and 75+, respectively, compared with eGFR ≥ 60 mL/min/1.73m²).

Limitations:

Fatigue hospitalization codes have not been validated; reference group limited to adults with at least 1 outpatient serum creatinine measurement; remaining potential for residual confounding.

Conclusions:

Declining kidney function was associated with increased incidence of hospitalization for fatigue. Further research into ways to address fatigue in the CKD population is warranted.

Trial Registration:

Not applicable (not a clinical trial).

Effects of intradialytic resistance exercises on physical performance, nutrient intake and quality of life among haemodialysis people: A systematic review and meta-analysis

OBJECTIVES

The aim of this systematic reviews was to synthesize the current studies for the effectiveness of intradialytic resistance exercises with usual care on HD people.

DESIGN

Meta-analysis of randomized controlled studies.

METHODS

A systematic search of seven electronic databases, including PubMed, EMBASE, the Cochrane Library, Web of Science, WanFang, China National Knowledge Infrastructure (CNKI) and SINOMED, was systematically searched up to May 2018. The reference lists of previously reported systematic review were also checked. Pooled analysis was used to determine effection of intradialytic resistance exercises for haemodialysis people. Physical performance, nutrient intake and quality of life were explored, by comparing the association between effect sizes.

RESULTS

Fourteen studies of 594 people were included. Compared with control groups, intradialytic resistance exercises significantly improve physical performance included 6-min walk test, sit-to-stand 30 and grip strength. However, no significant improvements were found in nutrient intakes such as dietary protein intake and quality of life.

Endurance-oriented training program with children and adolescents on maintenance hemodialysis to enhance dialysis efficacy-DiaSport

OBJECTIVE

Pediatric patients spend significant time on maintenance hemodialysis (HD) and traveling. They are often not capable of participating in sports activities. To assess the effects of exercise training during HD on dialysis efficacy in children and adolescents, we set up a multi-center randomized controlled trial (RCT).

METHODS

Patients on HD, age 6 to 18 years, were randomized either to 3× weekly bicycle ergometer training or to no training during HD for 12 weeks. Change in single-pool Kt/V (spKt/V) was the primary outcome parameter.

RESULTS

We randomized 54 patients of whom 45 qualified (23 in the intervention and 22 in the waiting control group, 14.5 ± 3.01 years, 32 male and 13 female) for the intention-to-treat (ITT) population. Only 26 patients finished study per-protocol (PP). Training was performed for an average of 11.96 weeks (0.14-13.14) at 2.08 ± 0.76 times per week and for a weekly mean of 55.52 ± 27.26 min. Single-pool Kt/V was similar in the intervention compared to the control group (1.70 [0.33] vs. 1.79 [0.55]) at V0 and (1.70 [0.36] vs. 1.71 [0.51]) at V1; secondary endpoints also showed no difference in both ITT and PP analysis. No significant adverse events were reported. No bleeding or needle dislocation occurred in 1670 training sessions.

CONCLUSIONS

Intradialytic bicycle training is safe, but does not improve dialysis efficacy and physical fitness. However, the study can be considered underpowered, particularly because of high dropout rates. Future studies need better strategies to increase motivation and compliance and other more effective/intensive exercise measures should be evaluated.

TRIAL REGISTRATION

The trial was registered in ClinicalTrials.Gov ( Clinicaltrials.gov identifier: NCT01561118) on March 22, 2012.

Dojuksan ameliorates tubulointerstitial fibrosis through irisin-mediated muscle-kidney crosstalk

BACKGROUND

Sarcopenia progresses in chronic kidney disease (CKD) and is positively correlated with mortality in end-stage kidney disease patients. Circulating irisin, an exercise-induced myokine, gradually decreases during CKD stage progression. Irisin inhibits the progression of kidney fibrosis, which is the final common outcome of CKD. Our preliminary study with C2C12 cells showed that Dojuksan, a herbal decoction, increases the expression of PGC1α (a regulator of irisin) and FNDC5 (a precursor of irisin).

HYPOTHESIS

Dojuksan may increase circulating irisin and prevent the progression of kidney fibrosis.

STUDY DESIGN AND METHODS

Unilateral ureteral obstruction (UUO) was performed on seven-week-old male C57BL/6 mice to induce kidney tubulointerstitial fibrosis. Dojuksan (50, 100, or 200 mg/kg/day) or losartan (1.5 mg/kg/day), a standard clinical treatment for CKD, was administered orally one day prior to surgery and continued for seven days thereafter. To determine the role of irisin released from muscles, TGFβ-stimulated murine proximal tubular epithelial cells (mProx24 cells) were treated with conditioned media (CM) from Dojuksan-treated C2C12 muscle cells transfected with FNDC5 siRNA.

RESULTS

UUO mice exhibited muscle wasting along with progressive kidney injury. Similar to losartan, Dojuksan ameliorated kidney inflammation and fibrosis in UUO mice. Dojuksan, but not losartan, increased plasma irisin concentration in UUO mice. Dojuksan significantly increased basal FNDC5 expression and inhibited TNFα-induced and indoxyl sulfate-induced FNDC5 down-regulation in C2C12 cells. The TGFβ-induced collagen I (COL1) up-regulation in mProx24 cells was effectively inhibited by CM from C2C12 cells after Dojuksan treatment. Moreover, irisin inhibited TGFβ-induced COL1 in mProx24 cells, which was not affected by CM from C2C12 cells transfected with FNDC5 siRNA.

CONCLUSION

Dojuksan ameliorates kidney fibrosis through irisin-mediated muscle-kidney crosstalk, suggesting that Dojuksan may be used as an alternative therapeutic agent against CKD.

Association of motivations and barriers with participation and performance in a pedometer-based intervention

BACKGROUND

A randomized trial of a pedometer-based intervention with weekly activity goals led to increased walking among dialysis patients. However, the association of participant-expressed motivations and barriers to participation and performance in such an intervention has not been determined.

METHODS

Thirty dialysis patients were randomized to a 12-week pedometer-based intervention with weekly step goals. Participants were asked about motivations and barriers to the increasing activity via weekly semi-scripted telephone interviews. We examined the association of these motivations and barriers with achieving weekly goals, reaching overall targets and increasing steps through multivariable linear and logistic regression analyses adjusted for age, sex, body mass index, dialysis modality and baseline steps.

RESULTS

The most common motivations were desire to maintain/improve functional ability (30%) and activity (30%). The most common barriers were health-related (33%). Motivation to maintain/improve functional ability was associated with achieving weekly goals 17.9% more often [95% confidence interval (CI) 1.7-34.2] and with a greater increase in steps (1524 steps; 95% CI 61-2989) than those lacking this motivation. Experiencing a health-related barrier was not associated with the decreased achievement of weekly goals but was associated with lower odds of reaching overall targets (odds ratio = 0.06; 95% CI 0.01-0.53) and a smaller increase in steps (-1640 steps, 95% CI -3244 to -36). No patients who reported weather/environmental barriers or safety concerns reached overall targets.

CONCLUSIONS

Participants who express a desire to maintain/improve functional ability may be particularly suited for activity interventions. Health-related setbacks should be met with revised goals. Reporting environmental or safety concerns may merit lowering overall targets.

Interventions to Preserve Cognitive Functioning Among Older Kidney Transplant Recipients

PURPOSE OF REVIEW

To summarize the research on effective interventions for preserving cognitive function and prevent cognitive decline in patients with end-stage kidney disease (ESKD) who are undergoing dialysis and/or kidney transplantation (KT).

RECENT FINDINGS

Among ESKD patients undergoing hemodialysis, exercise training has been administered through home-based and intradialytic interventions. Additionally, one pilot study identified intradialytic cognitive training, electronic brain games, as an intervention to preserve cognitive function among patients undergoing hemodialysis. Fewer studies have investigated interventions to preserver cognitive function among KT recipients. To date, the only randomized controlled trial in this population identified B-vitamin supplements as an intervention to preserve cognitive function. The evidence from these trials support a short-term benefit of cognitive and exercise training as well as B-vitamin supplementation among patients with ESKD. Future studies should: 1) replicate these findings, 2) identify interventions specific to KT candidates, and 3) investigate the synergistic impact of both cognitive and exercise training.

SUMMARY

Cognitive prehabilitation, with cognitive and/or exercise training, may be novel interventions for KT candidates that not only reduces delirium risk and long-term post-KT cognitive decline but also prevents dementia.

Leisure-Time Physical Activity and Mortality in CKD: A 1999-2012 NHANES Analysis

BACKGROUND

For patients with CKD, evidence on the optimal dose of physical activity and possible harm with excessive exercise is limited. This study aimed to analyze the dose-response association between leisure-time physical activity (LTPA) and mortality in those with CKD and explore the optimal dose or possible harm associated with increased levels of LTPA.

METHODS

4,604 participants with CKD from the 1999 to 2012 National Health and Nutrition Examination Surveys with linked mortality data obtained through 2015 were classified into 6 groups: 0, 1-149, 150-299, 300-599, 600-899, and ≥900 min/week based on the total duration of the self-reported LTPA. Multivariable-adjusted Cox proportional hazards models were used to examine dose-response associations between LTPA and mortality.

RESULTS

During the median follow-up of 114 months, 1,449 (31%) all-cause deaths were recorded. Compared to the inactive group (0 min/week), we observed a 22% lower risk of all-cause mortality (hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.63-0.97) among participants who performed 1-149 min per week for LTPA. The corresponding HRs and 95% CIs for all-cause mortality for 150-299 and 300-599 min/week of LTPA were 0.79 (0.64-0.97) and 0.74 (0.56-0.98). The benefit appeared to reach a threshold of a 43% (HR, 0.57; 95% CI, 0.36-0.91) lower risk of all-cause mortality among individuals performing 600-899 min/week for LTPA. Importantly, for ≥900 min/week of LTPA, the continued benefits were observed (HR, 0.62; 95% CI, 0.44-0.87).

CONCLUSION

LTPA was associated with lower mortality in those with CKD. The optimal dose was observed at the LTPA level of approximately 600-899 min/week, and there were still benefits rather than the excess risk with LTPA levels as high as ≥900 min/week. Therefore, clinicians should encourage inactive CKD patients to perform LTPA and do not need to discourage CKD patients who already adhere to long-term physical activity.

Effects of intradialytic cycling exercise on daily physical activity, physical fitness, body composition, and clinical parameters in high-volume online hemodiafiltration patients: a pilot randomized-controlled trial

PURPOSE

The mortality of dialysis patients treated with high-volume online hemodiafiltration (OL-HDF) is better than hemodialysis, but is still higher than healthy population. Low daily physical activity increases cardiovascular mortality. Addition of intradialytic exercise (IDX) program might improve physical activity and health status in OL-HDF patients. This pilot open-labeled randomized-controlled trial was conducted to evaluate the effects of IDX on physical activity and other clinical parameters in OL-HDF patients.

METHODS

Twelve OL-HDF patients were randomized into control (n = 6) or IDX (n = 6) groups. The subjects in IDX group were trained to exercise using a cycle ergometer for 60 min during each OL-HDF session. Physical activity measured as daily step count using a wrist-worn triaxial accelerometer, physical fitness, or cardiorespiratory fitness assessed by VO₂max and other physical performance tests, lean body mass determined by the Dual-energy X-ray absorptiometry (DXA), quality of life (QOL), and various parameters were compared between baseline and 6 months.

RESULTS

The baseline physical activity status was comparable. Following 6-month IDX, the physical activity was significantly improved in IDX group [+ 1048.79 (+ 741.50, + 2792.54) vs. - 362.06 (- 1626.82, - 167.47) steps/day, p = 0.01], while physical fitness and QOL were unchanged. The lean body mass parameters were preserved in the IDX group while seemed to decrease in the control group. Serum albumin was significantly increased in the IDX group (p = 0.01). The hemoglobin changes were significantly better (p = 0.01) and the erythropoietin resistance index was significantly lower in the IDX group (p = 0.03). Phosphate reduction was significantly greater in the IDX group (p = 0.04).

CONCLUSIONS

IDX could improve physical activity and other metabolic parameters in OL-HDF patients and these might contribute to further improvement in clinical and survival outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Registration: NCT03353844.

Effect of a Supervised Peridialytic Exercise Program on Serum Asymmetric Dimethylarginine in Maintenance Hemodialysis Patients

End-stage renal disease (ESRD) patients treated with maintenance haemodialysis (MHD) have alarmingly high atherosclerotic cardiovascular disease morbidity and mortality. Nitric oxide (NO) is the principal endogenous antiatherosclerotic molecule. Increased asymmetric dimethylarginine (ADMA), an endogenous NO synthase inhibitor, was strongly implicated in endothelial dysfunction, premature atherosclerosis, vascular events, and mortality. Regular physical exercise effectively decreased serum ADMA in several patient cohorts, but this potential benefit has not been specifically explored among MHD patients. Forty-four middle-aged ESRD patients treated with thrice-weekly MHD for ≥6 months completed a 6-months regimen of peridialytic lower limb exercise comprising predialytic 10-12 stretching cycles and 20-30 minutes of intradialytic pedaling cycles. Before and after the study, predialytic haemoglobin, serum ADMA, urea, creatinine, calcium, phosphorus, and C-reactive protein (CRP) were measured. Dialysis adequacy was assessed by single-pool Kt/V. The average total physical activity (PA) level was assessed by the International Physical Activity Questionnaire (IPAQ). P values <0.05 denoted a statistical significance. The overall level of PA, on both categorical and continuous scales, has significantly increased after application of the exercise program. However, S. ADMA increased from a median of 2375 to 3000 ng/mL (P=0.016). Thirty-one patients sustained an increase in S. ADMA (ADMA_Inc), whereas 13 patients had a declining or stable S. ADMA (ADMA_Dec). Compared with ADMA_Inc, ADMA_Dec patients had significantly higher Kt/V (P=0.02), higher grade of the basal general PA level (P=0.017), and significantly fewer intradialytic hypotension episodes (IDHs) (P=0.019). The increase in the S. ADMA and the poststudy S. ADMA level had statistically significant positive correlations with the number of IDHs (r = 0.401, P=0.007 and r = 0.305, P=0.044, respectively). A 6-month program of combined aerobic and resistance peridialytic exercise failed to reduce S. ADMA in most MHD patients studied. A modest S. ADMA decline, however, occurred in patients with higher basal PA levels, higher Kt/V, and less IDHs. A potential exercise benefit may be promoted by a multidisciplinary approach targeting increased PA, improved dialysis efficiency, and prevention of IDHs.

Sarcopenia in chronic kidney disease: what have we learned so far?

The term sarcopenia was first introduced in 1988 by Irwin Rosenberg to define a condition of muscle loss that occurs in the elderly. Since then, a broader definition comprising not only loss of muscle mass, but also loss of muscle strength and low physical performance due to ageing or other conditions, was developed and published in consensus papers from geriatric societies. Sarcopenia was proposed to be diagnosed based on operational criteria using two components of muscle abnormalities, low muscle mass and low muscle function. This brought awareness of an important nutritional derangement with adverse outcomes for the overall health. In parallel, many studies in patients with chronic kidney disease (CKD) have shown that sarcopenia is a prevalent condition, mainly among patients with end stage kidney disease (ESKD) on hemodialysis (HD). In CKD, sarcopenia is not necessarily age-related as it occurs as a result of the accelerated protein catabolism from the disease and from the dialysis procedure per se combined with low energy and protein intakes. Observational studies showed that sarcopenia and especially low muscle strength is associated with worse clinical outcomes, including worse quality of life (QoL) and higher hospitalization and mortality rates. This review aims to discuss the differences in conceptual definition of sarcopenia in the elderly and in CKD, as well as to describe etiology of sarcopenia, prevalence, outcome, and interventions that attempted to reverse the loss of muscle mass, strength and mobility in CKD and ESKD patients.

Protocolized exercise improves frailty parameters and lower extremity impairment: A promising prehabilitation strategy for kidney transplant candidates

BACKGROUND

Frailty and decreased functional status are risk factors for adverse kidney transplant (KT) outcomes. Our objective was to examine the efficacy of an exercise intervention on frailty and decreased functional status in a cohort of patients with advanced chronic kidney disease (CKD).

METHODS

We conducted a prospective study involving 21 adults with ≥stage 4 CKD who were (a) frail or pre-frail by Fried phenotype and/or (b) had lower extremity impairment [short physical performance battery score ≤10]. The intervention consisted of two supervised outpatient exercise sessions per week for 8 weeks.

RESULTS

Among our cohort, median participant age was 62 years (interquartile range, 53-67) and 85.7% had been evaluated for KT. Following the study, participants reported satisfaction with the intervention and multiple frailty parameters improved significantly, including fatigue, physical activity, walking time, and grip strength. Lower extremity impairment also improved (90.5%-61.9%, P = .03). No study-related adverse events occurred.

CONCLUSIONS

Preliminary data from this study suggest that a supervised, outpatient exercise intervention is safe, acceptable, feasible, and associated with improved frailty parameters, and lower extremity function, in patients with advanced CKD. Further studies are needed to confirm these findings and determine whether this prehabilitation strategy improves KT outcomes.

Twelve-week intradialytic cycling exercise improves physical functional performance with gain in muscle strength and endurance: a randomized controlled trial

Objective:

To evaluate the effect of intradialytic cycling exercise on physical functional performance with gain in muscle strength and endurance in end-stage renal disease patients with haemodialysis.

Design:

Randomized controlled trial, with repeated measurements at baseline and after 4, 8, and 12 weeks of intradialytic cycling exercise.

Setting:

A 50-bed haemodialysis centre in a regional hospital in Taiwan.

Subjects:

Seventy-six regular haemodialysis patients, recruited and equally and randomly assigned to exercise and control groups.

Intervention:

The intradialytic cycling exercise was performed for 12 weeks and comprised warm-up, main, and cool-down exercise phases. A stationary cycling equipment was used, which involved aerobic and resistance modalities. The intensity was maintained at somewhat hard exertion. Each intradialytic cycling exercise was implemented for 30 minutes, starting at the second hour of treatment.

Main measure:

Measured outcomes were 6-minute walk distance, time taken to complete 10 sit-to-stand-to-sit cycles and number of sit-to-stand-to-sit cycles in 60 seconds.

Results:

Average (standard deviation) participant age was 55.47 (13.00) years. Therefore, the 6-minute walk distance was significantly different at weeks 8 ( P = 0.01) and 12 ( P < 0.001) in the exercise group compared with that in the control group at baseline. Notably, sit-to-stand-to-sit outcomes ( P = 0.01) significantly influenced the 6-minute walk distance. Sit-to-stand-to-sit outcomes significantly improved in the exercise group ( P < 0.05).

Conclusion:

Twelve-week intradialytic exercise for patients on haemodialysis can improve physical functional performance with gain muscle strength and endurance. This is a safe and effective method for improving health.

Comparison of intradialytic versus home-based exercise programs on physical functioning, physical activity level, adherence, and health-related quality of life: pilot study

Intradialytic exercise (ID) programs are effective and safe for hemodialysis (HD) patients to avoid functional deterioration. However, exercise is not routinely undertaken in most HD units, and we do not know if home-based (HB) programs are as effective as ID programs. The purpose of this study was to compare the effects of 16 weeks of ID exercise versus a HB exercise program for HD patients. A total of 46 patients were randomly assigned to the ID group (n = 24) or HB group (n = 22). They completed a 16-week combined exercise program 3 times/week. We measured physical activity level, physical functioning, depression level, and health-related quality of life at baseline and after 16 weeks. A significant time effect was found in both groups for the physical activity level (p = 0.012). There was also a significant group-time interaction effect for the one-leg standing test (OLST) (p = 0.049) and a significant time effect for the Short Physical Performance Battery (p = 0.013), timed up-and-go test (p = 0.005), sit-to-stand-10 (p = 0.027), right and left hand handgrip (p = 0.044, p < 0.001), one-heel left leg raise (p = 0.019), and 6-minute walking (p = 0.006), depression (p = 0.017). HRQoL remained unchanged. There was no difference between the two interventions on the tested outcomes (besides OLST). Both interventions were associated with positive changes of the physical activity levels and physical function.

Association of Karnofsky Performance Status with waitlist mortality among older and younger adults awaiting kidney transplantation

Patients with end-stage renal disease (ESRD) have impaired functional status compared with the general population. We sought to explore the association between Karnofsky Performance Status (KPS) and death/delisting from the kidney transplantation waitlist and whether this association differed by age. Patients listed for single-organ kidney transplantation in the United Network for Organ Sharing/Organ Procurement and Transplantation Network from January 1, 2015, to January 1, 2018, were included. We performed competing-risk regression analyses to determine the association between KPS ("Severely impaired", "Moderately impaired", "Non-impaired") and death/delisting, with deceased-donor kidney transplantation as a competing risk. We tested for interactions between age and KPS on death/delisting. Of the 89,819 patients analyzed, 39% were impaired (KPS < 80) and 20% were aged ≥ 65 years. Older age and lower KPS were independently associated with higher risk of death/delisting (age 45-64 years, HR 1.97 [95% CI 1.73-2.24]; age ≥ 65 years, HR 3.62 [95% CI 3.33-3.92] compared with age < 45 years; moderately impaired, HR 1.68 [95% CI 1.45-1.95]; severely impaired, HR 4.80 [95% CI 3.71-6.21] compared with non-impaired). Lower KPS was associated with higher risk of death/delisting among all ages, but this effect was slightly less pronounced among individuals aged ≥ 65 years. Performance status should be used when counseling patients with ESRD on their risks for death/delisting.

Endurance training during maintenance hemodialysis in pediatric and adolescent patients-theory and best practice suggestions

Patients on maintenance hemodialysis (HD) spend significant sedentary time traveling to and receiving dialysis, which leaves little time for social or sport events. Also, chronic HD patients are not physically fit, too exhausted after HD, and are not necessarily motivated to perform sports. There is increasing evidence that endurance training during HD can both increase dialysis efficacy and improve the ability of patients to participate in social life. With limited spare time, how can we motivate patients to train? Would that training improve endurance and modify leisure activity choice? Since HD patients would be a captive audience, we would suggest that endurance training during HD would be a preferred solution, if pediatric and adolescent patients could be persuaded to participate. There are few data on how training should be organized, as well as which parameters are best markers of safety and efficacy. And, most importantly, motivational aspects for performing endurance training on a regular basis clearly have to be considered. It is therefore in any case important to assess whether training improves endurance and, thus, quality of life or also quality of care parameters.

Modifiable Physical Factors Associated With Physical Functioning for Patients Receiving Dialysis: A Systematic Review

Background: Patients receiving dialysis have reduced physical function, which is associated with unfavorable clinical outcomes and decreased quality of life. The authors aimed to identify and explore modifiable physical factors associated with physical function for patients receiving dialysis. Methods: Searches were performed in MEDLINE, Embase, Ovid Emcare, and The Cochrane Library in October 2018. Etiological studies involving dialysis populations that report association or predictive statistics between a modifiable physical factor and physical function were eligible for inclusion. Predictor variables were (1) modifiable via exercise and (2) considered an impairment in the International Classification of Functioning, Disability and Health. Results: Of 5384 titles screened, 23 studies were included. Thirteen studies focused on physical activity levels and muscle strength and the relationship with physical function while 2 studies investigated sedentary behavior. Twenty-one studies focused on hemodialysis populations. Studies related to physical activity levels displayed a moderately strong relationship with physical function, whereas muscle strength displayed a predominantly weak to moderate relationship. Conclusions: Physical activity levels, sedentary behavior levels, and muscle strength are related to physical function status for patients receiving dialysis. There is a need for robust longitudinal data to confirm the results of this investigation and for more focus on populations receiving peritoneal dialysis.

Effect of a pedometer-based walking intervention on body composition in patients with ESRD: a randomized controlled trial

BACKGROUND

A randomized trial of a pedometer-based intervention with weekly activity goals led to a modest increase in step count among dialysis patients. In a secondary analysis, we investigated the effect of this intervention on body composition.

METHODS

Sixty dialysis patients were randomized to standard care or a 6-month program consisting of 3 months of pedometers and weekly step count targets and 3 months of post-intervention follow-up. We obtained bioelectrical impedance spectroscopy (BIS) data on 54 of these patients (28 control, 26 intervention) and used linear mixed-modeling (adjusted for sex and dialysis modality) to estimate differences in change in total-body muscle mass (TBMM) adjusted for height2, fat mass (kg), and body mass index (BMI) (kg/m2) between control and intervention groups.

RESULTS

The median age of participants was 57.5 years (53-66), and 76% were men. At baseline, there was no significant difference between groups in age, BMI, race, or body composition, but there were more men in the intervention group. After 3 months, patients in the intervention group increased their average daily steps by 2414 (95% CI 1047, 3782) more than controls (p < 0.001), but there were no significant differences in body composition. However, at 6 months, participants in the intervention had a significantly greater increase from baseline in TBMM of 0.7 kg/m2 (95% CI 0.3, 1.13), decrease in fat mass (- 4.3 kg [95% CI -7.1, - 1.5]) and decrease in BMI (- 1.0 kg/m2 [95% CI -1.8, - 0.2]) relative to controls. In post-hoc analysis, each increase of 1000 steps from 0 to 3 months was associated with a 0.3 kg decrease in fat mass (95% CI 0.05, 0.5) from 0 to 6 months, but there was no dose-response relationship with TBMM/ht2 or BMI.

CONCLUSION

A pedometer-based intervention resulted in greater decreases in fat mass with relative preservation of muscle mass, leading to a greater decrease in BMI over time compared with patients not in the intervention. These differences were driven as much by worsening in the control group as by improvement in the intervention group. Step counts had a dose-response relationship with decrease in fat mass.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02623348). 02 December 2015.

Hemodynamic and perceptual responses to blood flow-restricted exercise among patients undergoing dialysis

End-stage kidney disease is associated with reduced exercise capacity, muscle atrophy, and impaired muscle function. While these may be improved with exercise, single modalities of exercise do not traditionally elicit improvements across all required physiological domains. Blood flow-restricted exercise may improve all of these physiological domains with low intensities traditionally considered insufficient for these adaptions. Investigation of this technique appeals, but is yet to be evaluated, in patients undergoing dialysis. With the use of a progressive crossover design, 10 satellite patients undergoing hemodialysis underwent three exercise conditions over 2 wk: two bouts (10 min) of unrestricted cycling during two consecutive hemodialysis sessions (condition 1), two bouts of cycling with blood flow restriction while off hemodialysis on 2 separate days (condition 2), and two bouts of cycling with blood flow restriction during two hemodialysis sessions (condition 3). Outcomes included hemodynamic responses (heart rate and blood pressure) throughout all sessions, participant-perceived exertion and discomfort on a Borg scale, and evaluation of ultrafiltration rates and dialysis adequacy (Kt/V) obtained post hoc. Hemodynamic responses were consistent regardless of condition. Significant increases in heart rate, systolic blood pressure, and mean arterial blood pressure (P < 0.05) were observed postexercise followed by a reduction in blood pressures during the 60-min recovery (12, 5, and 11 mmHg for systolic, diastolic, and mean arterial pressures, respectively). Blood pressures returned to predialysis ranges following the recovery period. Blood flow restriction did not affect ultrafiltration achieved or Kt/V. Hemodynamic safety and tolerability of blood flow restriction during aerobic exercise on hemodialysis is comparable to standard aerobic exercise.

Leisure-Time Physical Activity and Mortality in CKD: A 1999–2012 NHANES Analysis

<b><i>Background:</i></b> For patients with CKD, evidence on the optimal dose of physical activity and possible harm with excessive exercise is limited. This study aimed to analyze the dose-response association between leisure-time physical activity (LTPA) and mortality in those with CKD and explore the optimal dose or possible harm associated with increased levels of LTPA. <b><i>Methods:</i></b> 4,604 participants with CKD from the 1999 to 2012 National Health and Nutrition Examination Surveys with linked mortality data obtained through 2015 were classified into 6 groups: 0, 1–149, 150–299, 300–599, 600–899, and ≥900 min/week based on the total duration of the self-reported LTPA. Multivariable-adjusted Cox proportional hazards models were used to examine dose-response associations between LTPA and mortality. <b><i>Results:</i></b> During the median follow-up of 114 months, 1,449 (31%) all-cause deaths were recorded. Compared to the inactive group (0 min/week), we observed a 22% lower risk of all-cause mortality (hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.63–0.97) among participants who performed 1–149 min per week for LTPA. The corresponding HRs and 95% CIs for all-cause mortality for 150–299 and 300–599 min/week of LTPA were 0.79 (0.64–0.97) and 0.74 (0.56–0.98). The benefit appeared to reach a threshold of a 43% (HR, 0.57; 95% CI, 0.36–0.91) lower risk of all-cause mortality among individuals performing 600–899 min/week for LTPA. Importantly, for ≥900 min/week of LTPA, the continued benefits were observed (HR, 0.62; 95% CI, 0.44–0.87). <b><i>Conclusion:</i></b> LTPA was associated with lower mortality in those with CKD. The optimal dose was observed at the LTPA level of approximately 600–899 min/week, and there were still benefits rather than the excess risk with LTPA levels as high as ≥900 min/week. Therefore, clinicians should encourage inactive CKD patients to perform LTPA and do not need to discourage CKD patients who already adhere to long-term physical activity.