Effects of aerobic exercise on patients with pre-dialysis chronic kidney disease: a systematic review of randomized controlled trials

Cardiopulmonary fitness in children/adolescents with chronic kidney disease and the impact of exercise training: a systematic review and meta-analysis of observational study and randomized controlled trials

BACKGROUND

This systematic review and meta-analysis aimed to evaluate differences in cardiopulmonary fitness between healthy controls and children/adolescents with chronic kidney disease (CKD) and the effects of exercise training.

METHODS

PubMed, Embase, Scopus and Web of Science were searched for published studies from reception to 14 June 2023, and updated search on 15 October 2023. The included observational studies reported on cardiorespiratory fitness, included maximal oxygen uptake (VO2max), peak oxygen consumption (VO2peak) and 6-minute walk distance (6MWD), in children/adolescents with CKD and age-matched healthy controls, as well as clinical intervention trials of exercise training on cardiorespiratory fitness in samples of children and/or adolescents up to 19.

RESULTS

Fifteen observational studies and five clinical trials were included, respectively. The studies found that the mean cardiopulmonary fitness was 1.82 standardized mean differences (SMDs) units (95% confidence interval (95% CI) 1.43-2.20) lower in children/adolescents with CKD than in healthy controls or reference values. Except for pre-dialysis CKD patients, peritoneal dialysis, haemodialysis and kidney transplant recipients had significantly lower cardiorespiratory fitness than healthy controls. The results of a meta-analysis based on a pre-post single-arm trial showed that compared to baseline, exercise training improved the 6MWD by approximately 58.17 m (95% CI 16.27-100.06), with very low evidence.

CONCLUSIONS

This systematic review and meta-analysis of observational studies and clinical trials that included children/adolescents with CKD found that cardiorespiratory fitness is severely reduced in this population and that exercise training may be an effective strategy for improvement. Given the low evidence certainty, additional high-quality trials are necessary.

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.

Cardiovascular Disease in Chronic Kidney Disease: Implications of Cardiorespiratory Fitness, Race, and Sex

Cardiovascular disease (CVD) poses a major health burden in adults with chronic kidney disease (CKD). While cardiorespiratory fitness, race, and sex are known to influence the relationship between CVD and mortality in the absence of kidney disease, their roles in patients with CKD remain less clear. Therefore, this narrative review aims to synthesize the existing data on CVD in CKD patients with a specific emphasis on cardiorespiratory fitness, race, and sex. It highlights that both traditional and non-traditional risk factors contribute to CVD development in this population. Additionally, biological, social, and cultural determinants of health contribute to racial disparities and sex differences in CVD outcomes in patients with CKD. Although cardiorespiratory fitness levels also differ by race and sex, their influence on CVD and cardiovascular mortality is consistent across these groups. Furthermore, exercise has been shown to improve cardiorespiratory fitness in CKD patients regardless of race or sex. However, the specific effects of exercise on CVD risk factors in CKD patients, particularly across different races and sexes remains poorly understood and represent a critical area for future research.

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

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

The effect of aerobic exercise on oxidative stress in patients with chronic kidney disease: a systematic review and meta-analysis with trial sequential analysis

PURPOSE

The purpose of this study was to investigate how aerobic exercise affects oxidative stress (OS) in patients with chronic kidney disease (CKD).

METHODS

Retrieval dates range from the date the database was established to 19 July 2023, without languages being restricted. A meta-analysis and sensitivity analysis were conducted using RevMan 5.3 and Stata 16.0.

RESULTS

The meta-analysis showed that, compared to usual activity or no exercise, aerobic exercise significantly reduced the oxidative markers malondialdehyde (MDA) (mean differences (MD) - 0.96 (95% CI -1.33, - 0.59); p < 0.00001), advanced oxidation protein product (AOPP) (MD - 3.49 (95% CI - 5.05, - 1.93); p < 0.00001), F2-isoprostanes (F2-iso) (MD - 11.02 (95% CI - 17.79, - 4.25); p = 0.001). Aerobic exercise also increased the antioxidant marker superoxide dismutase (SOD) in CKD patients (standardized mean differences (SMD) 1.30 (95% CI 0.56, 2.04); p = 0.0005). Subgroup analysis showed a significant increase in glutathione peroxidase (GPX) in patients aged ≥60 years (SMD 2.11 (95% CI 1.69, 2.54); p < 0.00001). The change in total antioxidant capacity (TAC) after aerobic exercise was insignificant in patients with CKD. The trial sequential analysis supported aerobic exercise's effectiveness in improving MDA, SOD, AOPP, and F2-iso in patients with CKD.

CONCLUSION

The results of this review suggest that aerobic exercise improves OS indicators (MDA, SOD, AOPP, and F2-iso) in CKD patients compared to conventional treatment or no exercise and that the effects on GPX and TAC indicators need further confirmation. For better validation of benefits and exploration of the best aerobic exercise regimen to improve OS status with CKD, further studies with high methodological quality and large sample sizes are needed.

Influence of lower limb muscle isometric strength and cardiovascular parameters on locomotor capacity in children and adolescents

BACKGROUND

Although measures of exercise performance and physical activity are known to be related to 6-minute walk test (6mWT), the role of the strength of each muscle group of the lower limb in the locomotor capacity during the development period is unknown.

OBJECTIVE

To identify the role of the isometric strength of lower limb muscles and cardiovascular parameters on the locomotor capacity in children and adolescents, controlling for participants sex, age, and height.

METHODS

Participants (7 to 15 years old; female, n= 113; male, n= 128) were assessed for isometric strength (seven lower limb muscles), cardiovascular parameters (diastolic pressure, oxygen saturation, resting heart rate, respiratory rate), and 6mWT. Participants were split into nine age groups and separated by 1-year intervals.

RESULTS

Hip flexors-controlled for sex, age, and height-explained a meaningful percentage of the variance (R=2 0.45; p< 0.001) for 6mWT distance, and the resting heart rate explained a change in R2 of only 2% (p= 0.008).

CONCLUSIONS

Isometric strength of hip flexors explained ∼ 50% of the 6mWT distance, suggesting the importance of strength from an early age. Other factors, such as cardiovascular parameters, while relevant, may exert a secondary role on youth's capacity.

Association of Daily Physical Activity with Disability in Community-Dwelling Older Adults With/Without Chronic Kidney Disease

OBJECTIVES

Physical activity is recommended for disability prevention in the older adult population; however, the level of physical activity required for older adults with chronic kidney disease (CKD) remains unknown. This study aimed to examine the associations between daily physical activity and disability incidence in older adults with and without CKD to determine relevant daily physical activity levels.

DESIGN

Prospective observational study.

SETTING AND PARTICIPANTS

3,786 community-dwelling older adults aged ≥65 years.

MEASUREMENTS

Mean daily times spent in light- (LPA) and moderate-to-vigorous physical activity (MVPA) were measured using triaxial accelerometers. CKD was defined by a creatinine estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2. Disability incidence was identified as long-term care insurance certification during a 60-month follow-up period. Associations between physical activity and disability incidence were examined using Cox proportional hazard models stratified by the CKD status. Non-linear and linear associations were tested using the restricted cubic spline.

RESULTS

A total of 1,054 individuals were identified to have CKD. Disability incidence was higher in the CKD group than in the non-CKD group. The adjusted cox proportional hazard models indicated that a 10-minute increase in MVPA time was associated with lower disability incidence in the non-CKD group (hazard ratio [HR], 0.838; 95% confidence interval [CI]: 0.764-0.918) and the CKD group (HR, 0.859; 95% CI: 0.766-0.960). Linear associations were observed in MVPA for the non-CKD and CKD groups.

CONCLUSION

Increasing MVPA was associated with lower disability incidence in older adults with and without CKD. These findings can help devise disability prevention strategies for older CKD patients.