Impact of physical exercise in patients with chronic kidney disease: Sistematic review and meta-analysis

Identifying core symptom clusters based on symptom distress levels in patients with maintenance hemodialysis: a cross-sectional network analysis

BACKGROUND

To explore the symptom clusters of patients undergoing maintenance hemodialysis and construct a symptom network to identify the core symptoms and core symptom clusters, to provide reference for precise symptom management.

METHODS

Conveniently selected 354 patients with maintenance hemodialysis were surveyed cross-sectionally using the general information questionnaire, the Dialysis Symptom Index and the Kidney Disease Questionnaire. Symptom clusters were extracted using exploratory factor analysis, and core symptom clusters were identified using hierarchical regression and network analysis.

RESULTS

The most common and severe symptoms were fatigue, dry skin and itching, and the most distressing symptoms were fatigue, itching and trouble falling asleep. Within the symptom network, worry (rs = 1.0) had the highest strength, trouble staying asleep(rc = 0.01) had the highest closeness, and fatigue had the highest betweenness (rb = 30) and bridge strength (rbs = 0.53). A total of four symptom clusters were extracted, namely psychological symptom cluster, sleep disorder symptom cluster, uremia-related symptom cluster, and neurological symptom cluster. Hierarchical regression results showed that the psychological symptom cluster had the greatest impact on patients' quality of life.

CONCLUSIONS

Fatigue was the most severe symptom and the bridge symptom, the uremia-related symptom cluster caused the greatest distress for patients, worry was the core symptom, and the psychological symptom cluster was identified as the core cluster. Clinical staff can provide effective symptom management and improve patient symptom burden by establishing intervention strategies centered on these results.

Pretransplant Physical Activity and Cardiovascular Risk Factors in Kidney Transplant Candidates: A Cross-Sectional Study

Background/Objectives: Individuals with chronic kidney disease often face significant physical and clinical challenges, such as muscle weakness, fatigue, and reduced cardiorespiratory capacity, that impact their quality of life. Physical activity has emerged as an effective intervention to counteract these effects, with clinical guidelines recommending exercise as a standard treatment for kidney transplant recipients. The aim of this study was to assess pretransplant physical activity levels in a cohort of transplant patients and analyze their relationships with cardiovascular risk factors. Methods: A cross-sectional, analytical, and correlational study was conducted from September 2020 to June 2022 with a sample of 122 kidney transplant recipients assessed before kidney transplantation. Sociodemographic data, anthropometric data, comorbidities, renal replacement therapy types, and clinical and analytical data were collected from the patients' clinical records. Physical activity was assessed via the International Physical Activity Questionnaire. Results: The average time spent waiting for transplantation was 423 ± 405 days, which was longer (387 ± 524) in the group of those under 65 years than in those over 65 years (194 ± 256) (p = 0.010). The median energy expenditure was 1742 (IQR = 1719) METs. In addition, 15.6% of the participants reported inactivity. Men reported higher physical activity levels (median: 2076 METs/week; IQR: 2037) than women did (median: 1386 METs/week; IQR: 1238). A higher level of physical activity was found in non-dialysis patients, overweight patients, and those with a history of stroke. A significant positive correlation was found between physical activity levels and serum urea. Conclusions: Increased physical activity levels were observed in men and in participants under 65 years of age. Patients with cardiovascular risk factors, such as hypertension, diabetes mellitus, dyslipidemia, overweight and obesity, reported lower activity levels, whereas those with a prior history of cerebrovascular accidents engaged in more physical activity. This study highlights the importance of assessing physical activity and promoting exercise for chronic kidney disease patients awaiting kidney transplantation. Further research is needed to explore the evolution of physical activity in this population and its impact post-transplantation.

Resistance physical exercise modulates metabolic adipokines, decreases body weight, and improves glomerular filtration in patients with chronic kidney disease in hemodialysis

Chronic kidney disease (CKD) is a condition characterized by abnormalities in kidney structure and function that persist for more than 3 months. It is estimated that more than 800 million people in the world have a diagnosis of CKD. To remove the harmful metabolic substances from the body, people with CKD need to perform hemodialysis. Due to their beneficial effects against a wide range of clinical conditions, physical exercise is considered a non-pharmacological therapy. This study aimed to evaluate the beneficial effects of resistance exercise during hemodialysis on metabolic adipokines, myokines, body weight, and glomerular filtration rate in patients living with CKD. Briefly, the blood samples were collected in two moments: immediately before the start of the resistance exercise protocol and 1 week after the end of the protocol. Resistance exercise protocol was performed thrice a week for 12 weeks and applied during hemodialysis sessions. Here, resistance exercise increases the circulating irisin (14.56%; p = 0.0112), handgrip strength (5.70%; p = 0.0036), glomerular filtration rate (25.9%; p = 0.022) and significantly decreases adiponectin (- 55.7%; p = 0.0044), body weight (- 3.7%; p = 0.0001), glucose (- 22%; p = 0.009), and albumin levels (- 9.55%; p = 0.0001). Conversely, leptin levels (- 10.9%; p = 0.38), iron (3.05%; p = 0.705), ferritin (3.24%; p = 0.880), hemoglobin (- 0.52%; p = 0.75), total cholesterol (7.9%; p = 0.19), LDL (- 9.99%; p = 0.15) and HDL (- 4.8%; p = 0.45), did not change after resistance exercise. Interestingly, 1,25 hydroxyvitamin D levels were significantly increased (14.5%; p = 0.01) following resistance exercise. Considering the effect of sex (males vs. females), we found that irisin levels increased in females but not in males after the resistance exercise protocol. Furthermore, handgrip strength and body weight were different, indicating that males had the highest strength and weight. We demonstrated that both males and females had lower albumin levels after the resistance exercise protocol. In conclusion, we suggest that resistance exercise has beneficial effects in the CKD population by modulating adipokines and metabolic myokines and therefore can be used as a non-pharmacological adjunctive therapy in CKD patients undergoing HD.

Cardiorenal Syndrome in Right Heart Failure Due to Pulmonary Arterial Hypertension-The Right Ventricle as a Therapeutic Target to Improve Renal Function

Cardiorenal syndrome (CRS) due to right ventricular (RV) failure is a disease entity emerging as a key indicator of morbidity and mortality. The multifactorial aspects of CRS and the left-right ventricular interdependence complicate the link between RV failure and renal function. RV failure has a direct pathophysiological link to renal dysfunction by leading to systemic venous congestion in certain circumstances and low cardiac output in other situations, both leading to impaired renal perfusion. Indeed, renal dysfunction is known to be an independent predictor of mortality in patients with pulmonary arterial hypertension (PAH) and RV failure. Thus, it is important to further understand the interaction between the RV and renal function. RV adaptation is critical to long-term survival in patients with PAH. The RV is also known for its remarkable capacity to recover once the aggravating factor is addressed or mitigated. However, less is known about the renal potential for recovery following the resolution of chronic RV failure. In this review, we provide an overview of the intricate relationship between RV dysfunction and the subsequent development of CRS, with a particular emphasis on PAH. Additionally, we summarize potential RV-targeted therapies and their potential beneficial impact on renal function.

Spirit Interim Analysis: A Multicenter Prospective Observational Study of Outpatients with CKD and Decreased eGFR to Assess Therapeutic Algorithms, Disease Management and Quality of Life in Greece

Background: Chronic Kidney Disease (CKD) affects 8-16% of the population worldwide and is characterized by an estimated Glomerular Filtration Rate (eGFR) of less than 60 mL/min/1.73 m2 for more than 3 months. The main purpose of the study is to record the treatment algorithms and disease management of patients presenting for the first time to hospital-based nephrologists with a reduced eGFR and CKD diagnosis, under real-world clinical practice in Greece. Methods: This is the 6-month interim analysis of an ongoing, multicenter, observational, prospective, national study, which included 178 patients, with an eGFR between <60 and 15 mL/min/1.73 m2, presenting for the first time to nephrologists at 15 public hospital units. Results: The median age of the patients was 71 years old, with 39.6% of them categorized as CKD stage G3b. Of these patients, 71.6% and 33.7% suffered from arterial hypertension and type 2 diabetes mellitus, respectively; 78.7% of patients received antihypertensive and 38.5% antidiabetic medications. Calcium channel blocker usage increased with disease progression (from 52.2% at G3a, to 67.9% and 67.6% at G3b and G4, respectively), while that of angiotensin II receptor antagonists decreased (from 78.3% at G3a, to 41.5% and 17.6% at G3b and G4, respectively). A decrease in metformin usage and an increase in Dipeptidyl peptidase-4 inhibitor (DPP4i) usage was also observed upon disease progression. Furthermore, 18.5%, 32.0% and 7.7% of patients received Sodium-glucose cotransporter-2 inhibitors (SGLT2i) at the G3a, G3b and G4 stages, respectively. Conclusions: The interim analysis results contributed to the collection of real-world data for the therapeutic patterns and the management of CKD in Greece.

The impact of different exercise modalities on chronic kidney disease: an umbrella review of meta-analyses

Introduction

Exercise is widely recognized for its benefits to chronic kidney disease (CKD) patients. However, the specific impact of different exercise modalities on CKD-related outcomes remains unclear. This study sought to summarize the effects of different exercise modalities on the main outcomes impacted by CKD.

Methods

We searched for systematic review with meta-analysis in PubMed, Embase, Web of Science, Scopus, and Cochrane databases. We evaluated the methodological quality of included studies by AMSTAR2 tool and by individually evaluating the heterogeneity, sample power, and statistical significances from meta-analyses.

Results

We included 44 meta-analyses, encompassing 35,432 CKD patients in pre-dialysis and dialysis stages (peritoneal and hemodialysis). Data from meta-analyses with highly suggestive or strong evidence grading suggests that aerobic and combined training were most effective in improving cardiorespiratory fitness (main effect: 2.1, 95% CI: 0.8-3.4, and main effect: 3.4; 95% CI: 2.4-4.6, respectively). Combined training showed a consistent benefit in psychosocial domains (main effect: -7.3; 95% CI: -9.31 to -53). All exercise modalities significantly improve functional performance, except isometric training, which impacted just fistula maturation (main effect: 0.84; 95% CI: 0.5-1.2).

Conclusion

Exercise emerges as a potential non-pharmacological therapy for CKD patients. Tailoring exercise to specific outcomes appears to be crucial, as different exercise modalities exhibit varying effectiveness.

Preventive Effects of Resistance Training on Hemodynamics and Kidney Mitochondrial Bioenergetic Function in Ovariectomized Rats

Menopause occurs due to the depletion of the ovarian reserve, leading to a progressive decline in estrogen (E2) levels. This decrease in E2 levels increases the risk of developing several diseases and can coexist with chronic kidney disease (CKD). Arterial hypertension (AH) is another condition associated with menopause and may either contribute to or result from CKD. Ovariectomy (OVX) induces hypoestrogenism, which can lead to mitochondrial bioenergetic dysfunction in the kidneys. Previous studies have suggested that exercise training has beneficial effects on adults with CKD and AH. To investigate the effects of OVX and resistance training (RT) on hemodynamic parameters and mitochondrial bioenergetic function of the kidney, female Wistar rats were divided into ovariectomized (OVX) and intact (INT) groups. These rats were either kept sedentary (SED) or subjected to RT for thirteen weeks. The RT involved climbing a vertical ladder with a workload apparatus. Hemodynamic parameters were assessed via tail plethysmography. Mitochondrial respiratory function was evaluated with high-resolution respirometry. Gene expression related to the electron transport chain (ETC) and oxidative phosphorylation (OXPHOS) was evaluated by real-time qPCR. At week 13, key hemodynamic parameters (systolic blood pressure and mean arterial pressure) were significantly elevated in the OVX-SED group. Compared with those in the other groups, mitochondrial bioenergetics were impaired in the OVX-SED group. In contrast, the trained groups presented improved mitochondrial bioenergetic function compared with the sedentary groups. OVX led to reduced gene expression related to the mitochondrial ETC and OXPHOS, whereas RT both prevented this reduction and increased gene expression in the trained groups. Our results indicate that hypoestrogenism significantly decreases OXPHOS and ETC capacity in the kidneys of sedentary animals. However, RT effectively increased the expression of genes related to mitochondrial ETC and OXPHOS, thereby counteracting the effects of OVX.

Knowledge, Attitudes, and Practices Towards Exercise Therapy Among Patients with Stage 5 Chronic Kidney Disease on Regular Hemodialysis

Background

Exercise therapy could improve physical and psychological health in patients with chronic kidney disease (CKD). This study aimed to investigate knowledge, attitudes and practices (KAP) towards exercise therapy among patients with CKD stage 5 on regular hemodialysis.

Methods

The cross-sectional study was conducted between August 1st and 30th, 2023; KAP and demographic characteristics of CKD-5 patients were assessed with self-distributed questionnaire and analyzed using logistic regression and structural equation modeling (SEM). A higher score represented better knowledge, more positive attitude, and more proactive practice.

Results

In 513 collected questionnaires, mean scores for knowledge, attitudes, and practices were 9.5 ± 4.1 (possible range: 0-13), 31.9 ± 5.0 (possible range: 9-45), and 21.7 ± 9.3 (possible range: 9-45). Multivariate logistic regression analysis showed that education (OR = 1.8, 95% CI: 1.1-3.0, P = 0.02), income (OR = 1.7, 95% CI: 1.1-2.6, P = 0.02), and family support (OR = 3.8, 95% CI: 2.0-7.1, P < 0.001) were independently associated with higher knowledge scores. Knowledge score (OR = 5.1, 95% CI: 1.7-15.1, P < 0.001) and attitude score (OR = 7.3, 95% CI: 3.7-14.2, P < 0.001) were independently associated with higher practice scores. According to SEM, knowledge directly influenced attitude (β=1.3, P < 0.001), while attitude influenced practice (β=0.8, P < 0.001).

Conclusion

Patients with CKD-5 who underwent regular hemodialysis demonstrated insufficient knowledge, passive attitude and inactive practices towards exercise therapy. Improving knowledge and attitude through educational interventions might result in better practice.

Review of Exercise Interventions to Improve Clinical Outcomes in Nondialysis CKD

Exercise interventions in chronic kidney disease (CKD) have received growing interest, with over 30 meta-analyses published in the past 5 years. The potential benefits of exercise training in CKD range from slowing disease progression to improving comorbidities and quality of life. Nevertheless, there is a lack of large, randomized control trials in diverse populations, particularly regarding exercise in nondialysis-dependent CKD (NDD). When exercise interventions are implemented, they often lack fundamental features of exercise training such as progressive overload, personalization, and specificity. Furthermore, the physiology of exercise and CKD-specific barriers appear poorly understood. This review explores the potential benefits of exercise training in NDD, draws lessons from previous interventions and other fields, and provides several basic tools that may help improve interventions in research and practice.

The effect of exercise training in people with pre-dialysis chronic kidney disease: a systematic review with meta-analysis

BACKGROUND

Chronic kidney disease (CKD) is a global health issue with high mortality and economic costs. Exercise has potential benefits for pre-dialysis CKD management. This review examines the impact of exercise on CKD patients not on dialysis, focusing on improvement in various health parameters. Findings aim to inform the role of exercise in pre-dialysis CKD care.

METHODS

A systematic search of MEDLINE, EMBASE, the Cochrane Library of Controlled Trials, CINAHL, and SPORTDiscus, up to August 31, 2023, used key terms relating to pre-dialysis CKD and exercise. We pooled randomized controlled trials (RCTs) comparing exercise with usual care and conducted meta-analyses based on a random effects inverse variance model with the effect measure of mean difference.

RESULTS

Of 1162 identified studies, 37 RCTs met the inclusion criteria including 1248 participants. Significant improvements were identified for peak VO2, mean difference [MD] (2.66 mL/kg/min; 95% confidence interval [CI] 1.48, 3.83; p < 0.00001); the 6-min walk (MD 58.83 m; 95% CI 35.26, 82.41; p < 0.00001), timed up and go (standardised mean difference - 0.35; 95% CI - 0.54, - 0.15; p = 0.0006), 2-min step (MD 57.48 steps; 95% CI 27.80, 87.16; p = 0.0001), and sit to stand tests (MD 4.55 repetitions; 95% CI 1.49, 7.60; p = 0.004); short form [SF]-36 general health (MD 4.26; 95% CI 0.04, 8.47; p = 0.05); SF-36 mental component summary (MD 1.84; 95% CI 0.18, 3.51; p = 0.03); estimated glomerular filtration rate (MD 2.19 mL/min/1.73 m2; 95% CI 0.97, 3.50; p = 0.001); serum cystatin-C (MD - 0.06 mg/L; 95% CI - 0.11, - 0.02; p = 0.004); resting heart rate (MD - 1.97 bpm; 95% CI - 3.84, - 0.11; p = 0.04); triglycerides (MD - 12.97mg/dL; 95% CI - 17.30, - 8.63; p < 0.00001); glycosylated haemoglobin (MD - 0.25%; 95% CI - 0.50, - 0.01; p = 0.04); waist circumference (MD - 3.12 cm; 95% CI - 4.37, - 1.86; p < 0.00001); and interleukin-6 (MD - 2.24 pg/mL; 95% CI - 3.87. - 0.61; p = 0.007).

CONCLUSIONS

Analysis revealed improvements in aerobic capacity, functional ability, quality of life, estimated glomerular filtration rate, serum cystatin-C, resting heart rate, waist circumference, triglyceride, glycosylated haemoglobin, and interleukin-6 levels.

Acute Effect of Three Aerobic Exercise Intensities on Glomerular Filtration Rate in Healthy Older Adults

No consensus exists on whether acute aerobic exercise alters the glomerular filtration rate in older adults.

OBJECTIVE

To assess the immediate effects of three aerobic exercise intensities on the estimated glomerular filtration rate (eGFR) in healthy, sedentary older adults.

METHODS

Eighteen healthy, sedentary older adults (ten men and eight women) voluntarily participated in this study. The participants underwent three standardized aerobic exercise tests (100%, 80%, and 60% of the maximal heart rate) on a bicycle ergometer. Blood samples were collected to determine cholesterol, triacylglycerols, glucose, serum creatinine (Cr), Cystatin C (CysC) concentrations, and eGFR.

RESULTS

eGFR and serum concentrations of Cr and CysC were not modified at any exercise intensity. There was a negative correlation between blood total cholesterol vs. eGFR (R = -0.512, R = -0.582, R = -0.531; p < 0.05) at rest, 60%, and 100% of the maximal heart rate, respectively. In addition, a negative correlation existed for age vs. eGFR at 60% of the maximal heart rate (R = -0.516; p < 0.05).

CONCLUSIONS

Short-duration aerobic exercise of low, moderate, and vigorous intensity did not significantly affect eGFR and is considered safe for kidney function in healthy, sedentary older adults. However, regular monitoring of kidney function in older people engaged in moderate- and high-intensity exercise is advised.

Examining Self-Reported Physical Activity Levels Among Kidney Disease Patients in the United States Using the Behavioral Risk Factor Surveillance System (BRFSS) Database: A Retrospective Study

INTRODUCTION

Kidney diseases have a gradual and subtle onset, which usually results in end-stage renal disease with patients requiring renal replacement therapy. Though pharmacotherapy plays a crucial role, integrating lifestyle modifications like increased physical exercise has been associated with significant improvement in health for kidney disease patients.

AIMS

This study aims to retrospectively analyze the prevalence of self-reported physical activity among patients of kidney disease in the United States, based on demographic, socioeconomic, and healthcare access variables for the year 2021.

METHODOLOGY

Data was extracted from the Behavioral Risk Factor Surveillance System Web Enabled Analysis Tool (BRFSS WEAT) for the year 2021. Descriptive data, including numbers and percentages, was generated for each variable using cross-tabulations in the BRFSS WEAT. The data was stored in Microsoft Excel (Microsoft Corporation, Redmond, WA, USA), and statistical analysis was conducted using R version 4.3.1 (R Foundation for Statistical Computing, Vienna, Austria, https://www.R-project.org/). Statistical tests employed included the Chi-square test and Fisher's exact test to ensure robust and reliable results.

RESULTS

A total of 436,057 people participated in the BRFSS study. Out of this, 17,054 (39%) self-identified to the question "ever told you had kidney disease." In the past month, 10,004 (58.7%) participants having kidney disease were involved in physical activity, whereas 7,050 (41.3%) were not. Also, the level of physical activity among kidney disease participants was highest in ages 18-25 (75.5%), male gender (63.6%), White non-Hispanic race (59.4%), patients having advanced education (64.2%), employed (72.6%), high income (82.1%), and having routine checkup within the past one year (8,957, 58.3%).

CONCLUSION

Kidney disease patients in the United States who self-reported physical activity were found to have statistical significance between various demographic, socioeconomic, and last routine checkup variables. Prospectively, interventions must be designed to increase physical activity among kidney disease patients with a focus on high-risk demographic groups like older adults, people with lower socioeconomic status, and people who don't get regular checkups.

Does Physical Exercise Ameliorate Chronic Kidney Disease-Related Complications? The Case of Anaemia and Chronic Kidney Disease-Mineral Bone Disorder

BACKGROUND

Physical exercise (PE) can regulate inflammation, cardiovascular health, sarcopenia, anaemia, and bone health in the chronic kidney disease (CKD) population. Experimental and clinical studies both help us better understand the mechanisms that underlie the beneficial effects of the exercise, especially in renal anaemia and CKD-mineral bone disorders (CKD-MBDs). Here, we summarize this evidence, exploring the biological pathways involved, locally released substances, and crosstalk between tissues, but also the shortcomings of current knowledge.

SUMMARY

Anaemia: Both in healthy and CKD subjects, PE may mimic hypoxia, inhibiting PHDs; so hydroxylate HIF-α subunits may be translocated into the nucleus, resulting in dimerization of HIF-1α and HIF-1β, recruitment of p300 and CBP, and ultimately, binding to HREs at target genes to cause activation. However, in CKD subjects acute PE causes higher levels of lactate, leading to iron restriction by upregulating hepatic hepcidin expression, while chronic PE allows an increased lactate clearance and HIF-α and VEGFα levels, stimulating both erythropoiesis and angiogenesis.

CKD-MBD

PE may improve bone health decreasing bone resorption and increasing bone formation throughout at least three main pathways: (a) increasing osteoprotegerin and decreasing RANKL system; (b) decreasing cytokine levels; and (c) stimulating production of myokines and adipokines.

KEY MESSAGES

Future research needs to be defined to develop evidence-based exercise guidance to provide optimal benefit for CKD using exercise interventions as adjuvant therapy for CKD-related complications such as anaemia and CKD-MBD.

Effects of different inspiratory muscle training protocols on functional exercise capacity and respiratory and peripheral muscle strength in patients with chronic kidney disease: a randomized study

BACKGROUND

Pathological changes were observed in the diaphragm due to abnormal renal function in chronic kidney disease (CKD). Inspiratory muscle training (IMT) has been suggested for patients with CKD; however, the most appropriate intensity for IMT has not been determined. Therefore, this study aimed to investigate the effects of different IMT protocols on respiratory muscle strength, quadriceps femoris muscle strength (QMS), handgrip muscle strength (HGS), functional exercise capacity, quality of life (QoL), pulmonary function, dyspnoea, fatigue, balance, and physical activity (PA) levels in patients with CKD.

METHODS

This randomized, controlled, single-blind study included 47 patients and they were divided into three groups: Group 1 (n = 15, IMT with 10% maximal inspiratory pressure (MIP)), Group 2 (n = 16, IMT with 30% MIP), and Group 3(n = 16; IMT with 60% MIP). MIP, maximal expiratory pressure (MEP), 6-min walking test (6-MWT), QMS, HGS, QoL, pulmonary function, dyspnoea, fatigue, balance, and PA levels were assessed before and after eight weeks of IMT.

RESULTS

Increases in MIP, %MIP, 6-MWT distance, and %6-MWT were significantly higher in Groups 2 and 3 than in Group 1 after IMT (p < 0.05). MEP, %MEP, FEF25-75%, QMS, HGS, and QoL significantly increased; dyspnoea and fatigue decreased in all groups (p < 0.05). FVC, PEF, and PA improved only in Group 2, and balance improved in Groups 1 and 2 (p < 0.05).

CONCLUSIONS

IMT with 30% and 60% MIP similarly improves inspiratory muscle strength and functional exercise capacity. IMT with 30% is more effective in increasing PA. IMT is a beneficial method to enhance peripheral and expiratory muscle strength, respiratory function, QoL and balance, and reduce dyspnoea and fatigue. IMT with %30 could be an option for patients with CKD who do not tolerate higher intensities.

TRIAL REGISTRATION

This study was retrospectively registered (NCT06401135, 06/05/2024).

Trend analysis and prediction of the incidence and mortality of CKD in China and the US

BACKGROUND

Currently, limited research is available on the comparative analysis of chronic kidney disease (CKD) incidence and mortality rates between China and the United States. This study aimed to explore the trends in CKD incidence and mortality rates in both countries, as well as make some future predictions.

METHODS

The data on CKD incidence and mortality in China and the US from 1990 to 2019 were derived from the 2019 Global Burden of Disease database. A Joinpoint regression model was used to analyze temporal trends in CKD incidence and mortality. An age-period-cohort model was used to assess the effects of age, period, and birth cohort on CKD risk and forecast the age-standardized incidence rate (ASIR) and age-standardized mortality rate (ASMR) of CKD in China and the US over the next 15 years.

RESULTS

CKD incidence in China and the US showed an upward trend. Its mortality rate showed a downward trend in China but an upward one in the US. The relative risk (RR) of CKD incidence and mortality increases with age. The RR of CKD incidence in the 0-5 age group exceeds that in the 5-55 age group, and the RR for mortality surpasses that in the 5-35 age group. Over time, the RR of CKD incidence has gradually increased in China and the US. Individuals born in later birth cohorts had a lower RR of CKD incidence and mortality. The ASIR of CKD may increase in both China and the US, whereas its ASMR may decline over the next 15 years.

CONCLUSION

Screening measures should be strengthened among populations at high risk of CKD; prenatal examinations of pregnant women should be emphasized to reduce CKD incidence in newborns. It is imperative to increase health education and encourage individuals to adopt healthy lifestyles.

Physical exercise in kidney disease: A commonly undervalued treatment modality

BACKGROUND

Physical inactivity has been identified as a risk factor for multiple disorders and a strong association exists between chronic kidney disease (CKD) and a sedentary lifestyle. Even though physical activity is crucial in the development and progression of disease, the general focus of the current medical practice is the pharmacological perspective of diseases with inadequate emphasis on lifestyle intervention.

METHODS

In this narrative review we explain the pathophysiological mechanisms underlying the beneficial effects of physical exercise on CKD in addition to discussing the clinical studies and trials centred on physical exercise in patients with CKD.

RESULTS

Physical activity influences several pathophysiological mechanisms including inflammation, oxidative stress, vascular function, immune response and macromolecular metabolism. While exercise can initially induce stress responses like inflammation and oxidative stress, long-term physical activity leads to protective countermeasures and overall improved health. Trials in pre-dialysis CKD patients show that exercise can lead to reductions in body weight, inflammation markers and fasting plasma glucose. Furthermore, it improves patients' functional capacity, cardiorespiratory fitness and quality of life. The effects of exercise on kidney function have been inconsistent in these trials. In haemodialysis, peritoneal dialysis and kidney transplant patients exercise interventions improve cardiorespiratory fitness, walking capacity and quality of life. Combined training shows the best performance to increase peak oxygen uptake in haemodialysis patients. In kidney transplant recipients, exercise improves walking performance, quality of life and potentially arterial stiffness. However, exercise does not affect glucose metabolism, serum cholesterol and inflammation biomarkers. Long-term, adequately powered trials are needed to determine the long-term feasibility, and effects on quality of life and major clinical outcomes, including mortality and cardiovascular risk, in all CKD stages and particularly in kidney transplant patients, a scarcely investigated population.

CONCLUSION

Physical exercise plays a crucial role in ameliorating inflammation, oxidative stress, vascular function, immune response and macromolecular metabolism, and contributes significantly to the quality of life for patients with CKD, irrespective of the treatment and stage. Its direct impact on kidney function remains uncertain. Further extensive, long-term trials to conclusively determine the effect of exercise on major clinical outcomes such as mortality and cardiovascular risk remain a research priority.

Examining the Links Between Physical Activity, Sitting Time, and Renal Function in T2DM Patients

Background

Sitting time and physical activity are related to renal function among type 2 diabetes mellitus (T2DM); however, the mechanism of how it contributes to renal function is not well understood. The current study attempts to explore the relationship between sitting time and renal function among T2DM patients, with a particular focus on the mediating role of physical activity.

Methods

This research uses the data of 1761 Chinese T2DM patients from Ningxia Province. Sitting time and physical activity were obtained during a face-to-face survey, and renal function was assessed by the estimated glomerular filtration rate (eGFR). The bootstrap method is used to test the mediating effect.

Results

The research found that sitting time was negatively associated with eGFR and physical activity after controlling for covariates. Physical activity was positively associated with eGFR. Physical activity has mediated the relationship between sitting time and eGFR among T2DM patients (explaining 16.1% of the total variance).

Conclusion

The present findings suggest that sitting time negatively affects eGFR among T2DM patients and provides new evidence that physical activity could attenuate the association between sitting time and eGFR. Hence, intervention strategies focusing on sitting time and physical activity should be paid more attention in the future.

The Development of Dyslipidemia in Chronic Kidney Disease and Associated Cardiovascular Damage, and the Protective Effects of Curcuminoids

Chronic kidney disease (CKD) is a health problem that is constantly growing. This disease presents a diverse symptomatology that implies complex therapeutic management. One of its characteristic symptoms is dyslipidemia, which becomes a risk factor for developing cardiovascular diseases and increases the mortality of CKD patients. Various drugs, particularly those used for dyslipidemia, consumed in the course of CKD lead to side effects that delay the patient's recovery. Therefore, it is necessary to implement new therapies with natural compounds, such as curcuminoids (derived from the Curcuma longa plant), which can cushion the damage caused by the excessive use of medications. This manuscript aims to review the current evidence on the use of curcuminoids on dyslipidemia in CKD and CKD-induced cardiovascular disease (CVD). We first described oxidative stress, inflammation, fibrosis, and metabolic reprogramming as factors that induce dyslipidemia in CKD and their association with CVD development. We proposed the potential use of curcuminoids in CKD and their utilization in clinics to treat CKD-dyslipidemia.

Lifestyle Modifications and Nutritional and Therapeutic Interventions in Delaying the Progression of Chronic Kidney Disease: A Review

Chronic kidney disease (CKD) is a debilitating progressive illness that affects more than 10% of the world's population. In this literature review, we discussed the roles of nutritional interventions, lifestyle modifications, hypertension (HTN) and diabetes mellitus (DM) control, and medications in delaying the progression of CKD. Walking, weight loss, low-protein diet (LPD), adherence to the alternate Mediterranean (aMed) diet, and Alternative Healthy Eating Index (AHEI)-2010 slow the progression of CKD. However, smoking and binge alcohol drinking increase the risk of CKD progression. In addition, hyperglycemia, altered lipid metabolism, low-grade inflammation, over-activation of the renin-angiotensin-aldosterone system (RAAS), and overhydration (OH) increase diabetic CKD progression. The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend blood pressure (BP) control of <140/90 mmHg in patients without albuminuria and <130/80 mmHg in patients with albuminuria to prevent CKD progression. Medical therapies aim to target epigenetic alterations, fibrosis, and inflammation. Currently, RAAS blockade, sodium-glucose cotransporter-2 (SGLT2) inhibitors, pentoxifylline, and finerenone are approved for managing CKD. In addition, according to the completed Study of Diabetic Nephropathy with Atrasentan (SONAR), atrasentan, an endothelin receptor antagonist (ERA), decreased the risk of renal events in diabetic CKD patients. However, ongoing trials are studying the role of other agents in slowing the progression of CKD.

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.

Changes in body composition in relation to estimated glomerular filtration rate and physical activity in predialysis chronic kidney disease

Background

Early body composition changes, associated with physical inactivity and disease advancement are devastating for patient-related outcomes in predialysis chronic kidney disease (CKD), thus warranting a detailed analysis of body composition beyond conventional measures.

Methods

The study included 40 subjects diagnosed with CKD; recruited between January to May 2021. Body composition was measured using the multifrequency analyzer, InBody 770. International Physical Activity Questionnaire-Short Form was used to assess physical activity. Suitable statistical analyses were performed using SPSS 21.0.

Results

The mean age of the subjects was 58.68 ± 12.24 years. Sarcopenic obesity was prevalent in 62.5% of the subjects. Body mass index under identified obesity by 15% compared to percent body fat, especially in subjects with low muscle mass. The decline in a unit of estimated glomerular filtration rate (eGFR) significantly correlated with a decrease in weight (p = 0.02), body fat mass (p = 0.05), visceral fat area (p = 0.05), and phase angle (p = 0.01) with marginal changes in waist-hip ratio and extracellular water/total body water. The effect of physical activity on skeletal muscle mass was homogeneous between low and moderate levels, but significantly different from high activity level.

Conclusion

Changes in fat and fluid compartment were associated with eGFR decline, whereas higher physical activity positively affected body composition.

Decline in Walking Independence and Related Factors in Hospitalization for Dialysis Initiation: A Retrospective Cohort Study

Patients with chronic kidney disease require intervention planning because their physical function declines with worsening disease. Providers can work closely with patients during the induction phase of dialysis. This single-center, retrospective observational study aimed to investigate the rate of decline in walking independence during the induction phase of dialysis and the factors that influence this decline, and to provide information on prevention and treatment during this period. Of the 354 patients who were newly initiated on hemodialysis between April 2018 and January 2022, 285 were included in the analysis. The functional independence measure-walking score was used to sort patients into decreased walking independence (DWI; n = 46) and maintained walking independence (no DWI; n = 239) groups, and patient characteristics were compared. After adjusting for various factors by logistic regression analysis, we observed that age, high Charlson comorbidity index (CCI), C-reactive protein, and emergency dialysis start (EDS) were significant predictors of DWI. Even during the very short period of dialysis induction, as many as 16.1% of patients had DWI, which was associated with older age, higher CCI, higher inflammation, and EDS. Therefore, we recommend the early identification of patients with these characteristics and early rehabilitation.

Modifiable Lifestyle Behaviors and CKD Progression: A Narrative Review

Living a healthy lifestyle is one of the safest and most cost-effective ways to improve one's quality of life and prevent and/or manage chronic disease. As such, current CKD management guidelines recommend that patients adhere to a healthy diet, perform ≥150 minutes per week of physical activity, manage their body weight, abstain from tobacco use, and limit alcohol. However, there are limited studies that investigate the relationship between these lifestyle factors and the progression of CKD among people with established CKD. In this narrative review, we examine the reported frequencies of health lifestyle behavior engagement among individuals with non-dialysis-dependent CKD and the existing literature that examines the influences of diet, physical activity, weight management, alcohol consumption, and tobacco use on the progression of CKD, as measured by decline in GFR, incident ESKD, or elevated proteinuria or albuminuria in individuals with CKD. Many of the available studies are limited by length of follow-up and small sample sizes, and meta-analyses were limited because the studies were sparse and had heterogeneous classifications of behaviors and/or referent groups and of CKD progression. Further research should be done to determine optimal methods to assess behaviors to better understand the levels at which healthy lifestyle behaviors are needed to slow CKD progression, to investigate the effect of combining multiple lifestyle behaviors on important clinical outcomes in CKD, and to develop effective techniques for behavior change. Despite the lack of evidence of efficacy from large trials on the ability of lifestyle behaviors to slow CKD progression, maintaining a healthy lifestyle remains a cornerstone of CKD management given the undisputed benefits of healthy lifestyle behaviors on cardiovascular health, BP control, and survival.

Beyond the Calorie Paradigm: Taking into Account in Practice the Balance of Fat and Carbohydrate Oxidation during Exercise?

Recent literature shows that exercise is not simply a way to generate a calorie deficit as an add-on to restrictive diets but exerts powerful additional biological effects via its impact on mitochondrial function, the release of chemical messengers induced by muscular activity, and its ability to reverse epigenetic alterations. This review aims to summarize the current literature dealing with the hypothesis that some of these effects of exercise unexplained by an energy deficit are related to the balance of substrates used as fuel by the exercising muscle. This balance of substrates can be measured with reliable techniques, which provide information about metabolic disturbances associated with sedentarity and obesity, as well as adaptations of fuel metabolism in trained individuals. The exercise intensity that elicits maximal oxidation of lipids, termed LIPOXmax, FATOXmax, or FATmax, provides a marker of the mitochondrial ability to oxidize fatty acids and predicts how much fat will be oxidized over 45–60 min of low- to moderate-intensity training performed at the corresponding intensity. LIPOXmax is a reproducible parameter that can be modified by many physiological and lifestyle influences (exercise, diet, gender, age, hormones such as catecholamines, and the growth hormone-Insulin-like growth factor I axis). Individuals told to select an exercise intensity to maintain for 45 min or more spontaneously select a level close to this intensity. There is increasing evidence that training targeted at this level is efficient for reducing fat mass, sparing muscle mass, increasing the ability to oxidize lipids during exercise, lowering blood pressure and low-grade inflammation, improving insulin secretion and insulin sensitivity, reducing blood glucose and HbA_1c in type 2 diabetes, and decreasing the circulating cholesterol level. Training protocols based on this concept are easy to implement and accept in very sedentary patients and have shown an unexpected efficacy over the long term. They also represent a useful add-on to bariatric surgery in order to maintain and improve its weight-lowering effect. Additional studies are required to confirm and more precisely analyze the determinants of LIPOXmax and the long-term effects of training at this level on body composition, metabolism, and health.

Treadmill Exercise Training Ameliorates Functional and Structural Age-Associated Kidney Changes in Male Albino Rats

Aging is a biological process that impacts multiple organs. Unfortunately, kidney aging affects the quality of life with high mortality rate. So, searching for innovative nonpharmacological modality improving age-associated kidney deterioration is important. This study aimed to throw more light on the beneficial effect of treadmill exercise on the aged kidney. Thirty male albino rats were divided into three groups: young (3-4 months old), sedentary aged (23-24 months old), and exercised aged (23-24 months old, practiced moderate-intensity treadmill exercise 5 days/week for 8 weeks). The results showed marked structural alterations in the aged kidney with concomitant impairment of kidney functions and increase in arterial blood pressure with no significant difference in kidney weight. Also, it revealed that treadmill exercise alleviated theses effects in exercised aged group with reduction of urea and cystatin C. Exercise training significantly decreased glomerulosclerosis index, tubular injury score, and % area of collagen deposition. Treadmill exercise exerted its beneficial role via a significant reduction of C-reactive protein and malondialdehyde and increase in total antioxidant capacity. In addition, exercise training significantly decreased desmin immunoreaction and increased aquaporin-3, vascular endothelial growth factor, and beclin-1 in the aged kidney. This study clarified that treadmill exercise exerted its effects via antioxidant and anti-inflammatory mechanisms, podocyte protection, improving aquaporin-3 and vascular endothelial growth factor expression, and inducing autophagy in the aged kidney. This work provided a new insight into the promising role of aerobic exercise to ameliorate age-associated kidney damage.

Impact of Physical Activity and Natural Bioactive Compounds on Endothelial Dysfunction in Chronic Kidney Disease

Chronic kidney disease (CKD) represents a world-wide public health problem. Inflammation, endothelial dysfunction (ED) and vascular calcifications are clinical features of CKD patients that increase cardiovascular (CV) mortality. CKD-related CV disease pathogenic mechanisms are not only associated with traditional factors such as arterial hypertension and dyslipidemia, but also with ED, oxidative stress and low-grade inflammation. The typical comorbidities of CKD contribute to reduce the performance and the levels of the physical activity in nephropathic patients compared to healthy subjects. Currently, the effective role of physical activity on ED is still debated, but the available few literature data suggest its positive contribution. Another possible adjuvant treatment of ED in CKD patients is represented by natural bioactive compounds (NBCs). Among these, minor polar compounds of extra virgin olive oil (hydroxytyrosol, tyrosol and oleocanthal), polyphenols, and vitamin D seem to exert a beneficial role on ED in CKD patients. The objective of the review is to evaluate the effectiveness of physical exercise protocols and/or NBCs on ED in CKD patients.