The "Minimum Clinically Important Difference" in Frequently Reported Objective Physical Function Tests After a 12-Week Renal Rehabilitation Exercise Intervention in Nondialysis Chronic Kidney Disease

Assessing physical activity, mental health, and quality of life among older adults in Tehran, Iran: A cross-sectional study

BACKGROUND

The World Health Organisation (WHO/EMRO) funded research aimed to evaluate the effects of physical activity (PA) levels and their relationship with mental health and quality of life (QoL) among older adults in Tehran, Iran.

METHODS

A cross-sectional design was used, and data from five different regions were collected from 7500 individuals aged over 60 years using four questionnaires: The International PA Questionnaire (IPAQ), Quality of Life Questionnaire (WHOQOL-26), General Health Questionnaire (GHQ-28), and a preliminary individual characteristics questionnaire. The IPAQ assessed PA, while the GHQ-28 evaluated mental health. The WHOQOL-26 assessed quality of life in four areas: physical health, psychological well-being, social relationships, and environment. Data analysis was conducted on MLwiN 3.05, whereby multilevel regression models were constructed.

RESULTS

Results indicated that most participants had low levels of PA, with 74.4% meeting low levels of PA. No meaningful variation in mental health or QoL was attributable to PA behavior across regions. However, age, marital status, dependents, and MET PA were found to significantly predict mental health scores, while MET PA, age, number of dependents, social welfare, gender, and education significantly predicted QoL values.

CONCLUSION

The study highlights the need for executive support, coordination mechanisms, and appropriate infrastructures to improve the level of PA among Iranian older adults and promote mental well-being in this population.

Effectiveness of home-based cardiac rehabilitation interventions delivered via mHealth technologies: a systematic review and meta-analysis

BACKGROUND

Centre-based cardiac rehabilitation (CBCR) is underused due to low referral rates, accessibility barriers, and socioeconomic constraints. mHealth technologies have the potential to address some of these challenges through remote delivery of home-based cardiac rehabilitation (HBCR). This study aims to assess the effects of mHealth HBCR interventions compared with usual care and CBCR in patients with heart disease.

METHODS

We conducted a systematic review and meta-analysis of randomised controlled trials of mHealth HBCR interventions. Four electronic databases (MEDLINE, CENTRAL, CINAHL, and Embase) were searched from inception to March 31, 2023, with no restrictions on language or publication type. Eligible studies were randomised controlled trials of adult patients (age ≥18 years) with heart disease, comparing mHealth interventions with usual care or CBCR. The primary outcome of interest was aerobic exercise capacity, assessed with VO2 peak or 6-min walk test (6MWT). Quality of evidence was assessed using the GRADE system. This review was registered with PROSPERO, CRD42024544087.

FINDINGS

Our search yielded 9164 references, of which 135 were retained for full-text review. 13 randomised controlled trials met eligibility criteria and were included in the systematic review, involving 1508 adults with myocardial infarction, angina pectoris, or heart failure, or who had undergone revascularisation. Intervention duration ranged from 6 weeks to 24 weeks. Random-effects meta-analysis showed that, compared with usual care, mHealth HBCR significantly improved 6MWT (mean difference 24·74, 95% CI 9·88-39·60; 532 patients) and VO2 peak (1·77, 1·19-2·35; 359 patients). No significant differences were found between mHealth HBCR and CBCR. Quality of evidence ranged from low to very low across outcomes due to risk of bias and imprecision (small sample size).

INTERPRETATION

mHealth HBCR could improve access and health outcomes in patients who are unable to attend CBCR. Further research is needed to build a robust evidence base on the clinical effectiveness and cost-effectiveness of mHealth HBCR, particularly in comparison with CBCR, to inform clinical practice and policy.

FUNDING

None.

The Effect of Dark Chocolate Consumption on Arterial Function in Endurance Male Runners: Prospective Cohort Study

Foods rich in polyphenols have beneficial effects on health. This study aimed to examine the impact of dark chocolate on endurance runners' arterial function. Forty-six male amateur runners, aged 25-55, participated. The initial assessments included clinical testing, arterial stiffness measurements, and a cardiopulmonary exercise test. The participants then consumed 50 g of dark chocolate (70% cocoa) daily for two weeks, maintaining their usual training routine. After this period, the baseline assessment was repeated. The results showed significant improvements. Pulse wave velocity decreased by 11.82% (p < 0.001), and augmentation index by 19.47% (p < 0.001). Systolic brachial blood pressure reduced by 2.12% (p < 0.05), diastolic by 2.79% (p < 0.05), and mean pressure by 2.41% (p < 0.05). Central arterial pressure also decreased, with systolic by 1.24% (p < 0.05), diastolic by 2.80% (p < 0.05), and mean pressure by 2.43% (p < 0.05). Resting heart rate increased by 4.57% (p < 0.05) and left ventricular ejection time decreased by 4.89% (p < 0.05), particularly in athletes over 40. Exercise time increased by 2.16% (p < 0.05), heart rate (max) by 1.15% (p < 0.05), VO2max by 2.31% (p < 0.05), and anaerobic threshold shifted by 6.91% (p < 0.001) in exercise time and 6.93% (p < 0.001) in VO2max. In conclusion, dark chocolate improves arterial function in endurance runners, enhancing vascular health.

Exploring How the Kidney BEAM Physical Activity Digital Health Intervention Improved Mental Health-Related Quality of Life for People Living With Kidney Disease

Introduction

The Kidney BEAM randomized controlled trial reported clinically meaningful and statistically significant improvements in mental health-related quality of life (HRQoL), physical function (sit-to-stand-60, but not the physical component of HRQoL) and patient activation after a 12-week physical activity digital health intervention (DHI). This study explores factors that contributed to the effectiveness of Kidney BEAM through mixed methods analyses.

Methods

Quantitative data analysis was obtained from the recently published primary manuscript. Participants from the Kidney BEAM trial intervention group (n = 30) completed individualized semistructured interviews after the 12-week DHI. Interviews were analyzed using the framework method with inductive and deductive coding. Quantitative and qualitative data collection and analyses occurred concurrently, and independently, before combining using a mixed methods analysis with joint displays to triangulate datasets and further explore the primary findings.

Results

The integrated mixed methods analyses facilitated explanation of the primary findings. The Kidney BEAM intervention was shown to have mental and physical wellbeing benefits and enhanced self-management in this cohort of people living with chronic kidney disease (CKD). Elements that contributed to the effectiveness of the intervention were reported, including the different functional levels and gradual progression of the program, shared lived experiences with other participants, self-monitoring, the sense of achievement, taking back control of their health, moving beyond medications, and feeling safe and confident to exercise.

Conclusion

Elements of the Kidney BEAM intervention that contributed to the main quantitative trial findings were identified. This will allow researchers and practitioners to maximize the effectiveness of DHIs to enhance healthy behaviors in people living with CKD.

Effect of Pulmonary Rehabilitation on Exercise Capacity, Dyspnea, Fatigue, and Peripheral Muscle Strength in Patients With Post-COVID-19 Syndrome: A Systematic Review and Meta-analysis

OBJECTIVE

To establish the effects of pulmonary rehabilitation (PR) in patients with persistent symptoms after COVID-19 infection. In addition, to compare the modalities of PR services (face-to-face and telerehabilitation) and the duration of PR in weeks (4-8 weeks and >8 weeks).

DATA SOURCES

PubMed/MEDLINE, Embase (Elsevier), Central/Cochrane Library, SciELO Citation Index (Web of Science), and CINAHL.

STUDY SELECTION

Studies determining the effects of PR in patients with post-COVID-19 syndrome were included and grouped according to PR delivery modality.

DATA EXTRACTION

Data extraction and quality assessment were independently performed by 2 reviewers. The methodological quality was assessed using the Cochrane Risk of Bias Tool 1 (RoB-1).

DATA SYNTHESIS

The literature search retrieved 1406 articles, of which 7 studies explored the effects of PR on patients with post-COVID-19 syndrome, with 188 patients randomized to PR. The mean age of participants was 50 years and 49% were women. Meta-analysis showed an increase in exercise capacity with PR compared with control (6-minute walking test: mean difference: 60.56 m, 95% confidence interval: 40.75-80.36), a reduction in fatigue (Fatigue Severity Scale: -0.90, -1.49 to -0.31) but no change in dyspnea (-0.57, -1.32 to 0.17) and muscle strength (3.03, -1.89 to 7.96). There were no differences between telerehabilitation and face-to-face PR regarding effects on peripheral muscle strength (P=.42), dyspnea (P=.83), and fatigue (P=.34). There were no differences between programs 4-8 weeks and >8 weeks regarding exercise capacity (P=.83), peripheral muscle strength (P=.42), and dyspnea (P=.76).

CONCLUSIONS

PR improves exercise capacity and reduces fatigue in patients with post-COVID-19 syndrome. Duration of PR (4-8 weeks vs > 8 weeks) or PR modality (telerehabilitation vs face-to-face) did not affect outcomes but data were limited and based on subgroup analysis. Further evidence is required to determine the optimal delivery mode and duration of PR for post-COVID-19 syndrome.

Multi-Modal Prehabilitation in Thoracic Surgery: From Basic Concepts to Practical Modalities

Over the last two decades, the invasiveness of thoracic surgery has decreased along with technological advances and better diagnostic tools, whereas the patient's comorbidities and frailty patterns have increased, as well as the number of early cancer stages that could benefit from curative resection. Poor aerobic fitness, nutritional defects, sarcopenia and "toxic" behaviors such as sedentary behavior, smoking and alcohol consumption are modifiable risk factors for major postoperative complications. The process of enhancing patients' physiological reserve in anticipation for surgery is referred to as prehabilitation. Components of prehabilitation programs include optimization of medical treatment, prescription of structured exercise program, correction of nutritional deficits and patient's education to adopt healthier behaviors. All patients may benefit from prehabilitation, which is part of the enhanced recovery after surgery (ERAS) programs. Faster functional recovery is expected in low-risk patients, whereas better clinical outcome and shorter hospital stay have been demonstrated in higher risk and physically unfit patients.

Epimeric vitamin D and cardiovascular structure and function in advanced CKD and after kidney transplantation

BACKGROUND

25-hydroxyvitamin D can undergo C-3 epimerization to produce 3-epi-25(OH)D3. 3-epi-25(OH)D3 levels decline in chronic kidney disease (CKD), but its role in regulating the cardiovascular system is unknown. Herein, we examined the relationship between 3-epi-25(OH)D3, and cardiovascular functional and structural endpoints in patients with CKD.

METHODS

We examined n = 165 patients with advanced CKD from the Cardiopulmonary Exercise Testing in Renal Failure and After Kidney Transplantation (CAPER) study cohort, including those who underwent kidney transplant (KTR, n = 76) and waitlisted patients who did not (NTWC, n = 89). All patients underwent cardiopulmonary exercise testing and echocardiography at baseline, 2 months and 12 months. Serum 3-epi-25(OH)D3 was analyzed by liquid chromatography-tandem mass spectrometry.

RESULTS

Patients were stratified into quartiles of baseline 3-epi-25(OH)D3 (Q1: <0.4 ng/mL, n = 51; Q2: 0.4 ng/mL, n = 26; Q3: 0.5-0.7 ng/mL, n = 47; Q4: ≥0.8 ng/mL, n = 41). Patients in Q1 exhibited lower peak oxygen uptake [VO2Peak = 18.4 (16.2-20.8) mL/min/kg] compared with Q4 [20.8 (18.6-23.2) mL/min/kg; P = .009]. Linear mixed regression model showed that 3-epi-25(OH)D3 levels increased in KTR [from 0.47 (0.30) ng/mL to 0.90 (0.45) ng/mL] and declined in NTWC [from 0.61 (0.32) ng/mL to 0.45 (0.29) ng/mL; P < .001]. Serum 3-epi-25(OH)D3 was associated with VO2Peak longitudinally in both groups [KTR: β (standard error) = 2.53 (0.56), P < .001; NTWC: 2.73 (0.70), P < .001], but was not with left ventricular mass or arterial stiffness. Non-epimeric 25(OH)D3, 24,25(OH)2D3 and the 25(OH)D3:24,25(OH)2D3 ratio were not associated with any cardiovascular outcome (all P > .05).

CONCLUSIONS

Changes in 3-epi-25(OH)D3 levels may regulate cardiovascular functional capacity in patients with advanced CKD.

Exercise for chronic kidney disease: effects on vascular and cardiopulmonary function

Patients with chronic kidney disease (CKD) have an exacerbated prevalence of cardiovascular disease (CVD). Vascular dysfunction, characterized by impaired endothelial function and arterial stiffness, and markedly low cardiorespiratory fitness levels are hallmark manifestations of the disease that contribute to the CVD burden. Despite advancements in blood pressure and lipid lowering pharmacological therapies, CVD remains markedly prevalent across the spectrum of CKD. This highlights a stagnation in effective clinical strategies to improve cardiovascular health and reinforces the critical need for adjuvant lifestyle strategies such as physical activity and exercise training to be incorporated into routine clinical care. This narrative review provides an overview of the known effects of exercise on vascular and cardiopulmonary function across the spectrum of CKD. The physiological mechanisms of vascular dysfunction that serve as exercise-specific therapeutic targets are highlighted and future perspectives are discussed.

Aquatic high-intensity interval training (HIIT) may be similarly effective to land-based HIIT in improving exercise capacity in people with chronic conditions: a systematic review and meta-analysis

Objective

To investigate the effect of aquatic high-intensity interval training (AHIIT) on exercise capacity in people with chronic conditions.

Design

Systematic review and meta-analysis.

Participants

Adults (age ≥18 years) with any chronic conditions (long duration, continuing health problems).

Data sources

The databases Medline, EMBASE, CINAHL, SPORTSDiscus, PEDro and The Cochrane Library were searched from inception to 11 August 2023.

Eligibility criteria

Randomised or non-randomised controlled trials of adults reporting one or more chronic conditions were included, comparing the effect of AHIIT with a non-exercising control group, land-based high-intensity interval training (LBHIIT) or aquatic moderate-intensity continuous training (AMICT).

Results

Eighteen trials with 868 participants with chronic musculoskeletal, respiratory, cardiovascular, metabolic or neurological conditions were included. Adherence to AHIIT was high, ranging from 84% to 100%. There was moderate certainty in evidence according to the Grading of Recommendations Assessment, Development and Evaluation system for a moderate beneficial effect on exercise capacity standardised mean differences (SMD) 0.78 (95% CI 0.48 to 1.08), p<0.00001) of AHIIT compared with a non-exercising control group. There was moderate certainty in evidence for no difference of effects on exercise capacity (SMD 0.28 (95% CI -0.04 to 0.60), p=0.08) of AHIIT compared with LBHIIT. There was moderate certainty in evidence for small effect on exercise capacity (SMD 0.45 (95% CI 0.10 to 0.80), p=0.01) of AHIIT compared with AMICT.

Conclusion

There are beneficial effects of AHIIT on exercise capacity in people with a range of chronic conditions. AHIIT has similar effects on exercise capacity as LBHIIT and may represent an alternative for people unable to perform LBHIIT.

PROSPERO registration number

CRD42022289001.

Measurement properties of performance-based measures to assess physical function in chronic kidney disease: recommendations from a COSMIN systematic review

Background

There is wide heterogeneity in physical function tests available for clinical and research use, hindering our ability to synthesize evidence. The aim of this review was to identify and evaluate physical function measures that could be recommended for standardized use in chronic kidney disease (CKD).

Methods

MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, CINAHL, Scopus and Web of Science were searched from inception to March 2022, identifying studies that evaluated a clinimetric property (validity, reliability, measurement error and/or responsiveness) of an objectively measured performance-based physical function outcomes using the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) methodology and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) based recommendations. Studies with individuals of all ages and of any stage of CKD were included.

Results

In total, 50 studies with 21 315 participants were included. Clinimetric properties were reported for 22 different physical function tests. The short physical performance battery (SPPB), Timed-up-and-go (TUG) test and Sit-to-stand tests (STS-5 and STS-60) had favorable properties to support their use in CKD and should be integrated into routine use. However, the majority of studies were conducted in the hemodialysis population, and very few provided information regarding validity or reliability.

Conclusion

The SPPB demonstrated the highest quality of evidence for reliability, measurement error and construct validity amongst transplant, CKD and dialysis patients. This review is an important step towards standardizing a core outcome set of tools to measure physical function in research and clinical settings for the CKD population.

Effects of Different Exercises on Physical Function, Dialysis Adequacy, and Health-Related Quality of Life in Maintenance Hemodialysis Patients: A Systematic Review and Network Meta-Analysis

BACKGROUND

Clinical guidelines recommend exercise training for patients undergoing maintenance hemodialysis (MHD). However, the effectiveness of different types of exercise remains uncertain.

OBJECTIVES

The aims of the study were to compare and rank the effect of different types of exercise on walking capacity, cardiorespiratory fitness, dialysis adequacy, and health-related quality of life (HRQOL) in patients undergoing MHD.

METHODS

Eight databases (four English and four Chinese) were searched from inception to January 1, 2022. Randomized controlled trials evaluating the efficacy of different exercises for patients undergoing MHD were included. Two independent reviewers screened the literature, extracted data, assessed the risk of bias, and evaluated the certainty of evidence. A frequentist random-effect network meta-analysis was conducted.

RESULTS

Ninety trials with 4,084 participants comparing 15 types of exercise were included, reporting on the six-minute walking test (45 trials), peak oxygen uptake (22 trials), dialysis adequacy (30 trials), and HRQOL (23 trials). Network meta-analysis showed that the most effective intervention for walking capacity was intradialytic aerobic exercise combined with blood flow restriction with a mean difference and 95% confidence interval of 97.35 (11.89-182.81), for peak oxygen uptake it was non-intradialytic combined aerobic and resistance exercise with a value of 4.35 (2.25-6.44), for dialysis adequacy it was intradialytic combined aerobic and resistance exercise with a value of 0.17 (0.06-0.28), for the physical component summary of HRQOL it was intradialytic aerobic exercise with a value of 4.93 (2.31-7.54), and for the mental component summary of HRQOL it was non-intradialytic combined aerobic and resistance exercise with a value of 6.36 (0.45-12.27). Ultimately, intradialytic combined aerobic and resistance exercise could improve all the above outcomes compared to usual care.

CONCLUSIONS

This study concluded that intradialytic combined aerobic and resistance exercise is optimal for MHD patients due to its significant positive effects on multiple outcomes. Walking capacity can be further enhanced by combining blood flow restriction with exercise. For improving dialysis adequacy, intradialytic exercise proves to be more effective than non-intradialytic exercise. Further well-designed clinical trials are needed to investigate the effects of exercise with varying durations, intensities, and frequencies.

Exercise interventions for adults after liver transplantation

BACKGROUND

The finding that exercise is inversely related to metabolic syndrome after transplantation is novel and suggests that exercise interventions might provide a means for reducing metabolic syndrome complications in liver transplantation recipients. The use of exercise for increasing the physical activity daily levels by more frequent, higher intensity, and longer duration of training sessions, or the sum of these components may be necessary to counteract the effects of the pretransplant reduced activity, metabolic disturbances, and post-transplant immunosuppression, as well as improve physical function and aerobic capacity following liver transplantation. Regular physical activity has a long-term positive impact on recovery following various surgical procedures including transplantation, giving people the opportunity to return to an active life with their families, in society, and in their professional life. Likewise, specific muscle strength training may attenuate the loss of strength after liver transplantation.

OBJECTIVES

To evaluate the benefits and harms of exercise-based interventions in adults after liver transplantation compared to no exercise, sham interventions, or another type of exercise.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 2 September 2022.

SELECTION CRITERIA

We included randomised clinical trials in liver transplantation recipients comparing any type of exercise with no exercise, sham interventions, or another type of exercise.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. all-cause mortality; 2. serious adverse events; and 3. health-related quality of life. Our secondary outcomes were 4. a composite of cardiovascular mortality and cardiac disease; 5. aerobic capacity; 6. muscle strength; 7. morbidity; 8. non-serious adverse events; and 9. cardiovascular disease post-transplantation. We assessed risk of bias of the individual trials using RoB 1, described the interventions using the TIDieR checklist, and used GRADE to assess certainty of evidence.

MAIN RESULTS

We included three randomised clinical trials. The trials randomised 241 adults with liver transplantation, of which 199 participants completed the trials. The trials were conducted in the USA, Spain, and Turkey. They compared exercise versus usual care. The duration of the interventions ranged from two to 10 months. One trial reported that 69% of participants who received the exercise intervention were adherent to the exercise prescription. A second trial reported a 94% adherence to the exercise programme, with participants attending 45/48 sessions. The remaining trial reported a 96.8% adherence to the exercise intervention during the hospitalisation period. Two trials received funding; one from the National Center for Research Resources (US) and the other from Instituto de Salud Carlos III (Spain). The remaining trial did not receive funding. All trials were at an overall high risk of bias, derived from high risk of selective reporting bias and attrition bias in two trials. The results on all-cause mortality showed a higher risk of death in the exercise group versus the control group, but these results are very uncertain (risk ratio (RR) 3.14, 95% confidence interval (CI) 0.74 to 13.37; 2 trials, 165 participants; I² = 0%; very low-certainty evidence). The trials did not report data on serious adverse events excluding mortality or non-serious adverse events. However, all trials reported that there were no adverse effects associated with exercise. We are very uncertain on whether exercise compared with usual care has a beneficial or harmful effect on health-related quality of life assessed using the 36-item Short Form Physical Functioning subscale at the end of the intervention (mean difference (MD) 10.56, 95% CI -0.12 to 21.24; 2 trials, 169 participants; I² = 71%; very low-certainty evidence). None of the trials reported data on composite of cardiovascular mortality and cardiovascular disease, and cardiovascular disease post-transplantation. We are very uncertain if there are differences in aerobic capacity in terms of VO2peak at the end of the intervention between groups (MD 0.80, 95% CI -0.80 to 2.39; 3 trials, 199 participants; I² = 0%; very low-certainty evidence). We are very uncertain if there are differences in muscle strength at end of the intervention between groups (MD 9.91, 95% CI -3.68 to 23.50; 3 trials, 199 participants; I² = 44%; very low-certainty evidence). One trial measured perceived fatigue using the Checklist Individual Strength (CIST). Participants in the exercise group showed a clinically important lower degree of fatigue perception than participants in the control group, with a mean reduction of 40 points in the CIST (95% CI 15.62 to 64.38; 1 trial, 30 participants).  We identified three ongoing studies.

AUTHORS' CONCLUSIONS

Based on very low-certainty evidence in our systematic review, we are very uncertain of the role of exercise training (aerobic, resistance-based exercises, or both) in affecting mortality, health-related quality of life, and physical function (i.e. aerobic capacity and muscle strength) in liver transplant recipients. There were few data on the composite of cardiovascular mortality and cardiovascular disease, cardiovascular disease post-transplantation, and adverse event outcomes. We lack larger trials with blinded outcome assessment, designed according to the SPIRIT statement and reported according to the CONSORT statement.

The effect of a novel, digital physical activity and emotional well-being intervention on health-related quality of life in people with chronic kidney disease: trial design and baseline data from a multicentre prospective, wait-list randomised controlled trial (kidney BEAM)

BACKGROUND

Physical activity and emotional self-management has the potential to enhance health-related quality of life (HRQoL), but few people with chronic kidney disease (CKD) have access to resources and support. The Kidney BEAM trial aims to evaluate whether an evidence-based physical activity and emotional wellbeing self-management programme (Kidney BEAM) leads to improvements in HRQoL in people with CKD.

METHODS

This was a prospective, multicentre, randomised waitlist-controlled trial, with health economic analysis and nested qualitative studies. In total, three hundred and four adults with established CKD were recruited from 11 UK kidney units. Participants were randomly assigned to the intervention (Kidney BEAM) or a wait list control group (1:1). The primary outcome was the between-group difference in Kidney Disease Quality of Life (KDQoL) mental component summary score (MCS) at 12 weeks. Secondary outcomes included the KDQoL physical component summary score, kidney-specific scores, fatigue, life participation, depression and anxiety, physical function, clinical chemistry, healthcare utilisation and harms. All outcomes were measured at baseline and 12 weeks, with long-term HRQoL and adherence also collected at six months follow-up. A nested qualitative study explored experience and impact of using Kidney BEAM.

RESULTS

340 participants were randomised to Kidney BEAM (n = 173) and waiting list (n = 167) groups. There were 96 (55%) and 89 (53%) males in the intervention and waiting list groups respectively, and the mean (SD) age was 53 (14) years in both groups. Ethnicity, body mass, CKD stage, and history of diabetes and hypertension were comparable across groups. The mean (SD) of the MCS was similar in both groups, 44.7 (10.8) and 45.9 (10.6) in the intervention and waiting list groups respectively.

CONCLUSION

Results from this trial will establish whether the Kidney BEAM self management programme is a cost-effective method of enhancing mental and physical wellbeing of people with CKD.

TRIAL REGISTRATION

NCT04872933. Registered 5th May 2021.

Reliability and validity of the incremental shuttle walk test in patients with fully ambulatory multiple sclerosis

BACKGROUND

Functional exercise capacity evaluation is crucial to monitor treatment effects and disease progression in people with multiple sclerosis (pwMS). Compared to other tests, the incremental shuttle walking test (ISWT), which more accurately reflects cardiovascular responses, may be more useful for assessing exercise capacity. The aim of the study is to investigate the reliability and validity of the ISWT.

METHODS

Thirty-six pwMS with an Expanded Disability Status Scale (EDSS) score<4.5 between the ages of 25 and 65 were included in the study. The subjects underwent practice (ISWT-p) before undergoing the test-retest protocol in order to rule out the ISWT learning effect (ISWT-1 - ISWT-2). ISWT-1 and ISWT-2 were administered with a 3-7 day interval for test-retest reliability. Six-minutes walking test (6MWT) were applied for concurrent validity. The EDSS, pulmonary function tests, Fatigue Impact Scale (FIS), respiratory muscle strength [maximum inspiratory and expiratory pressure (MIP-MEP)] measurements were made for convergent validity.

RESULTS

ISWT was found to have excellent test-retest reliability with an ICC value of 0.97. The area under the curve value was 0.904 indicating that ISWT has a good performance for predicting disease severity. The moderate correlation between ISWT and 6MWT (rho: 0.68, p<0,001) proved concurrent validity. It was also moderately correlated with EDSS, MEP (rho: -0.58 and 0.47 respectively), weakly correlated with MIP and FIS (rho:0.37 and -0.36, respectively) while not correlated with pulmonary function tests.

CONCLUSION

The ISWT had excellent test-retest reliability, acceptable criterion and construct validity in ambulatory MS patients.

Physical activity and exercise training in cystic fibrosis

BACKGROUND

Physical activity (including exercise) may form an important part of regular care for people with cystic fibrosis (CF). This is an update of a previously published review.

OBJECTIVES

To assess the effects of physical activity interventions on exercise capacity by peak oxygen uptake, lung function by forced expiratory volume in one second (FEV1), health-related quality of life (HRQoL) and further important patient-relevant outcomes in people with cystic fibrosis (CF).

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. The most recent search was on 3 March 2022. We also searched two ongoing trials registers: clinicaltrials.gov, most recently on 4 March 2022; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), most recently on 16 March 2022.  SELECTION CRITERIA: We included all randomised controlled trials (RCTs) and quasi-RCTs comparing physical activity interventions of any type and a minimum intervention duration of two weeks with conventional care (no physical activity intervention) in people with CF.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected RCTs for inclusion, assessed methodological quality and extracted data. We assessed the certainty of the evidence using GRADE.  MAIN RESULTS: We included 24 parallel RCTs (875 participants). The number of participants in the studies ranged from nine to 117, with a wide range of disease severity. The studies' age demographics varied: in two studies, all participants were adults; in 13 studies, participants were 18 years and younger; in one study, participants were 15 years and older; in one study, participants were 12 years and older; and seven studies included all age ranges. The active training programme lasted up to and including six months in 14 studies, and longer than six months in the remaining 10 studies. Of the 24 included studies, seven implemented a follow-up period (when supervision was withdrawn, but participants were still allowed to exercise) ranging from one to 12 months. Studies employed differing levels of supervision: in 12 studies, training was supervised; in 11 studies, it was partially supervised; and in one study, training was unsupervised. The quality of the included studies varied widely. This Cochrane Review shows that, in studies with an active training programme lasting over six months in people with CF, physical activity probably has a positive effect on exercise capacity when compared to no physical activity (usual care) (mean difference (MD) 1.60, 95% confidence interval (CI) 0.16 to 3.05; 6 RCTs, 348 participants; moderate-certainty evidence). The magnitude of improvement in exercise capacity is interpreted as small, although study results were heterogeneous. Physical activity interventions may have no effect on lung function (forced expiratory volume in one second (FEV1) % predicted) (MD 2.41, 95% CI ‒0.49 to 5.31; 6 RCTs, 367 participants), HRQoL physical functioning (MD 2.19, 95% CI ‒3.42 to 7.80; 4 RCTs, 247 participants) and HRQoL respiratory domain (MD ‒0.05, 95% CI ‒3.61 to 3.51; 4 RCTs, 251 participants) at six months and longer (low-certainty evidence). One study (117 participants) reported no differences between the physical activity and control groups in the number of participants experiencing a pulmonary exacerbation by six months (incidence rate ratio 1.28, 95% CI 0.85 to 1.94) or in the time to first exacerbation over 12 months (hazard ratio 1.34, 95% CI 0.65 to 2.80) (both high-certainty evidence); and no effects of physical activity on diabetic control (after 1 hour: MD ‒0.04 mmol/L, 95% CI ‒1.11 to 1.03; 67 participants; after 2 hours: MD ‒0.44 mmol/L, 95% CI ‒1.43 to 0.55; 81 participants; moderate-certainty evidence). We found no difference between groups in the number of adverse events over six months (odds ratio 6.22, 95% CI 0.72 to 53.40; 2 RCTs, 156 participants; low-certainty evidence). For other time points (up to and including six months and during a follow-up period with no active intervention), the effects of physical activity versus control were similar to those reported for the outcomes above. However, only three out of seven studies adding a follow-up period with no active intervention (ranging between one and 12 months) reported on the primary outcomes of changes in exercise capacity and lung function, and one on HRQoL. These data must be interpreted with caution. Altogether, given the heterogeneity of effects across studies, the wide variation in study quality and lack of information on clinically meaningful changes for several outcome measures, we consider the overall certainty of evidence on the effects of physical activity interventions on exercise capacity, lung function and HRQoL to be low to moderate.

AUTHORS' CONCLUSIONS

Physical activity interventions for six months and longer likely improve exercise capacity when compared to no training (moderate-certainty evidence). Current evidence shows little or no effect on lung function and HRQoL (low-certainty evidence). Over recent decades, physical activity has gained increasing interest and is already part of multidisciplinary care offered to most people with CF. Adverse effects of physical activity appear rare and there is no reason to actively discourage regular physical activity and exercise. The benefits of including physical activity in an individual's regular care may be influenced by the type and duration of the activity programme as well as individual preferences for and barriers to physical activity. Further high-quality and sufficiently-sized studies are needed to comprehensively assess the benefits of physical activity and exercise in people with CF, particularly in the new era of CF medicine.

Relationship between quadriceps thickness and 60-second sit-to-stand test in patients with chronic kidney disease

BACKGROUND

This study aimed to evaluate the relationship between quadriceps muscle thickness and functional performance on the 60s sit-to-stand test (60s-STS), the six-minute walk test (6MWT), and handgrip strength in non-dialytic stage 4 and 5 chronic kidney disease (CKD) patients.

METHODS

This was a cross-sectional study that evaluated 40 CKD patients aged between 30-70 years. Participants were submitted to an assessment that included quadriceps muscle thickness evaluated by a portable ultrasound. Functional performance tests included the 60s-STS, distance walked in the 6MWT, and handgrip strength. Also, body composition evaluated using electrical bioimpedance analysis and physical activity level through the short version of International Physical Activity were measured. Multiple linear regression was used to investigate the relationship between the quadriceps thickness and functional performance.

RESULTS

Quadriceps muscle thickness was correlated to 60s-STS (R2 = 43.6%; 95% CI = 0.022 - 0.665; β = 0.34; p = 0.037). Also, a moderate correlation between this muscle thickness and appendicular skeletal muscle (ALM) was found in CKD patients (r = 0.603, p <0.001). No relationship was found between quadriceps muscle thickness with the 6MWT and handgrip strength.

CONCLUSION

Quadriceps muscle thickness is associated to 60s-STS, thus our results demonstrate the repercussions of the disease on the musculoskeletal system.

Effect of Cardiac Rehabilitation on Glomerular Filtration Rate Using Serum Cystatin C Concentration in Patients With Cardiovascular Disease and Renal Dysfunction

PURPOSE

Among patients with chronic kidney disease (CKD), little is known about whether the effect of cardiac rehabilitation (CR) on renal function differs across baseline estimated glomerular filtration rate using the serum concentration of cystatin C (eGFRcys). The aim of this study was to evaluate the effect of CR on renal function in patients with CKD.

METHODS

We performed a retrospective cohort study of patients with CKD (15 ≤ eGFRcys < 60 mL/min/1.73 m2) who participated in our CR program for cardiovascular disease. First, the patients were divided into three groups according to the baseline severity of the eGFRcys: G3a, G3b, and G4 groups. We compared the eGFRcys before and after the CR in each group. Second, to determine the association of baseline eGFRcys with the effect of CR, we fitted a linear regression model using the percent change in the eGFRcys (%ΔeGFRcys) as an outcome.

RESULTS

Of the 203 patients, 122 were in G3a, 60 were in G3b, and 21 were in G4 groups. The mean improvement of eGFRcys in each group was 1.3, 3.1, and 4.8 mL/min/1.73 m2, respectively. The %ΔeGFRcys was larger among patients with lower baseline eGFRcys (0.47% greater improvement of %ΔeGFRcys/one lower baseline eGFRcys; 95% CI, 0.23-0.72%). This association remained significant after adjustment for potential confounders (0.63% greater improvement of %ΔeGFRcys/one lower baseline eGFRcys; 95% CI, 0.35-0.91%).

CONCLUSIONS

The effect of CR on renal function was greater in patients with worse renal dysfunction measured by eGFRcys. A CR program could be useful for patients with severe renal dysfunction and it might have a beneficial effect on their renal function.

Effects of a Partially Supervised Conditioning Program in Cystic Fibrosis: An International Multicenter, Randomized Controlled Trial (ACTIVATE-CF)

Rationale: The long-term effects of vigorous physical activity (PA) on lung function in cystic fibrosis are unclear. Objectives: To evaluate effects of a 12-month partially supervised PA intervention using motivational feedback. Methods: In a parallel-arm multicenter randomized controlled trial (ACTIVATE-CF), relatively inactive patients aged at least 12 years were randomly assigned (1:1 ratio) to an intervention group or control group. The intervention group consented to add 3 hours of vigorous PA per week, whereas the control group was asked not to change their PA behavior. Primary endpoint was change in percent predicted FEV1 (ΔFEV1) at 6 months. Secondary endpoints included PA, exercise capacity, exercise motives, time to first exacerbation and exacerbation rates, quality of life, anxiety, depression, stress, and blood glucose control. Data were analyzed using mixed linear models. Measurements and Main Results: A total of 117 patients (40% of target sample size) were randomized to an intervention (n = 60) or control group (n = 57). After 6 months, ΔFEV1 was significantly higher in the control group compared with the intervention group (2.70% predicted [95% confidence interval, 0.13-5.26]; P = 0.04). The intervention group reported increased vigorous PA compared with the control group at each study visit, had higher exercise capacity at 6 and 12 months, and higher PA at 12 months. No effects were seen in other secondary outcomes. Conclusions: ACTIVATE-CF increased vigorous PA and exercise capacity, with effects carried over for the subsequent 6 months, but resulted in better FEV1 in the control group.

Exercise training for adults undergoing maintenance dialysis

BACKGROUND

Dialysis treatments weigh heavily on patients' physical and psychosocial health. Multiple studies have assessed the potential for exercise training to improve outcomes in adults undergoing dialysis. However, uncertainties exist in its relevance and sustainable benefits for patient-important outcomes. This is an update of a review first published in 2011.

OBJECTIVES

To assess the benefits and safety of regular structured exercise training in adults undergoing dialysis on patient-important outcomes including death, cardiovascular events, fatigue, functional capacity, pain, and depression. We also aimed to define the optimal prescription of exercise in adults undergoing dialysis.

SEARCH METHODS

In this update, we conducted a systematic search of the Cochrane Kidney and Transplant Register of Studies up to 23 December 2020. The Register includes studies identified from CENTRAL, MEDLINE, EMBASE, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov as well as kidney-related journals and the proceedings of major kidney conferences.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs of any structured exercise programs of eight weeks or more in adults undergoing maintenance dialysis compared to no exercise or sham exercise.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the search results for eligibility, extracted the data and assessed the risk of bias using the Cochrane risk of bias tool. Whenever appropriate, we performed random-effects meta-analyses of the mean difference in outcomes. The primary outcomes were death (any cause), cardiovascular events and fatigue. Secondary outcomes were health-related quality of life (HRQoL), depression, pain, functional capacity, blood pressure, adherence to the exercise program, and intervention-related adverse events.

MAIN RESULTS

We identified 89 studies involving 4291 randomised participants, of which 77 studies (3846 participants) contributed to the meta-analyses. Seven studies included adults undergoing peritoneal dialysis. Fifty-six studies reported aerobic exercise interventions, 21 resistance exercise interventions and 19 combined aerobic and resistance training within the same study arm. The interventions lasted from eight weeks to two years and most often took place thrice weekly during dialysis treatments. A single study reported death and no study reported long-term cardiovascular events. Five studies directly assessed fatigue, 46 reported HRQoL and 16 reported fatigue or pain through their assessment of HRQoL. Thirty-five studies assessed functional capacity, and 21 reported resting peripheral blood pressure. Twelve studies reported adherence to exercise sessions, and nine reported exercise-related adverse events. Overall, the quality of the included studies was low and blinding of the participants was generally not feasible due to the nature of the intervention. Exercise had uncertain effects on death, cardiovascular events, and the mental component of HRQoL due to the very low certainty of evidence. Compared with sham or no exercise, exercise training for two to 12 months may improve fatigue in adults undergoing dialysis, however, a meta-analysis could not be conducted. Any exercise training for two to 12 months may improve the physical component of HRQoL (17 studies, 656 participants: MD 4.12, 95% CI 1.88 to 6.37 points on 100 points-scale; I² = 49%; low certainty evidence). Any exercise training for two to 12 months probably improves depressive symptoms (10 studies, 441 participants: SMD -0.65, 95% CI -1.07 to -0.22; I² = 77%; moderate certainty evidence) and the magnitude of the effect may be greater when maintaining the exercise beyond four months (6 studies, 311 participants: SMD -0.30, 95% CI 0.14 to -0.74; I² = 71%). Any exercise training for three to 12 months may improve pain (15 studies, 872 participants: MD 5.28 95% CI -0.12 to 10.69 points on 100 points-scale; I² = 63%: low certainty evidence) however, the 95% CI indicates that exercise training may make little or no difference in the level of pain. Any exercise training for two to six months probably improves functional capacity as it increased the distance reached during six minutes of walking (19 studies, 827 participants: MD 49.91 metres, 95% CI 37.22 to 62.59; I² = 34%; moderate certainty evidence) and the number of sit-to-stand cycles performed in 30 seconds (MD 2.33 cycles, 95% CI 1.71 to 2.96; moderate certainty evidence). There was insufficient evidence to assess the safety of exercise training for adults undergoing maintenance dialysis. The results were similar for aerobic exercise, resistance exercise, and a combination of both aerobic and resistance exercise.

AUTHORS' CONCLUSIONS

It is uncertain whether exercise training improves death, cardiovascular events, or the mental component of HRQoL in adults undergoing maintenance dialysis. Exercise training probably improves depressive symptoms, particularly when the intervention is maintained beyond four months. Exercise training is also likely to improve functional capacity. Low certainty evidence suggested that exercise training may improve fatigue, the physical component of quality of life, and pain. The safety of exercise training for adults undergoing dialysis remains uncertain.

The FRAILMar Study Protocol: Frailty in Patients With Advanced Chronic Kidney Disease Awaiting Kidney Transplantation. A Randomized Clinical Trial of Multimodal Prehabilitation

Introduction: Frailty is very frequent among patients with chronic kidney disease (CKD) who are awaiting deceased donor kidney transplantation (KT), and transplant outcomes are worsened in those frail recipients. Frailty and poor fitness powerfully predict mortality, kidney graft survival, and healthcare utilization after KT. Intervention is essential to improve survival and quality of life for frail CKD patients, regardless of their age. Studies of post-transplant physical therapy intervention have been met with limited success, in large part due to high dropout rates. A pre-transplant clinical framework for multimodal prehabilitation interventions including physical therapy, nutritional measures, and psychological support scheduled during the KT waiting list period may improve patient retention and compliance, better mitigate the effects of frailty and poor fitness after KT, and improve main outcomes in frail CKD patients.

Main Objective: To study the effectiveness, feasibility, and safety of multimodal prehabilitation (exercise, nutritional plans, psychological advice) in KT candidates.

Methods: Randomized controlled clinical trial in 38 frail and 76 non-frail KT candidates. The prehabilitation program will consist of physical exercise (24 sessions, 8 weeks), nutritional supplementation, and psychological advice. The primary endpoint will be a composite achievement of clinical and functional main outcomes in frail and non-frail KT candidates at 90 days post-transplantation. Secondary outcomes include changes in exercise capacity, physical activity, gait speed, respiratory and peripheral muscle strength, muscle size, body composition, performance in activities of daily living (basic and instrumental), anxiety and depression symptoms, and health-related quality of life. Feasibility of the intervention will be also analyzed.

Expected Results: Multimodal prehabilitation is a feasible and effective intervention to decrease bad outcomes at 90 days post-KT by 25 and 12.5% in frail and non-frail patients, respectively.

Clinical Trial Registration:clinicaltrials.gov (NCT04701398), date: 2021, January 8th (Protocol version: Frailmar_vers2).

Exercise intolerance in kidney diseases: physiological contributors and therapeutic strategies

Exertional fatigue, defined as the overwhelming and debilitating sense of sustained exhaustion that impacts the ability to perform activities of daily living, is highly prevalent in chronic kidney disease (CKD) and end-stage renal disease (ESRD). Subjective reports of exertional fatigue are paralleled by objective measurements of exercise intolerance throughout the spectrum of the disease. The prevalence of exercise intolerance is clinically noteworthy, as it leads to increased frailty, worsened quality of life, and an increased risk of mortality. The physiological underpinnings of exercise intolerance are multifaceted and still not fully understood. This review aims to provide a comprehensive outline of the potential physiological contributors, both central and peripheral, to kidney disease-related exercise intolerance and highlight current and prospective interventions to target this symptom. In this review, the CKD-related metabolic derangements, cardiac and pulmonary dysfunction, altered physiological responses to oxygen consumption, vascular derangements, and sarcopenia are discussed in the context of exercise intolerance. Lifestyle interventions to improve exertional fatigue, such as aerobic and resistance exercise training, are discussed, and the lack of dietary interventions to improve exercise tolerance is highlighted. Current and prospective pharmaceutical and nutraceutical strategies to improve exertional fatigue are also broached. An extensive understanding of the pathophysiological mechanisms of exercise intolerance will allow for the development of more targeted therapeutic approached to improve exertional fatigue and health-related quality of life in CKD and ESRD.

Effect of continuous positive airway pressure on maximal exercise capacity in patients with obstructive sleep apnea: a systematic review and meta-analysis

STUDY OBJECTIVES

Exercise capacity is impaired in obstructive sleep apnea (OSA). There are conflicting reports on the effect of continuous positive airway pressure (CPAP) on maximal exercise capacity. The objective of this review was to determine if there is a change in exercise capacity and anaerobic threshold following CPAP treatment in OSA patients.

METHODS

We conducted a systematic review and meta-analyses to summarize the changes in peak rate of oxygen uptake (V̇O₂ peak) or maximum rate of oxygen uptake (V̇O2 max) and anaerobic threshold (AT) during cardiopulmonary exercise testing following CPAP intervention in patients with OSA. A systematic literature review was conducted to identify published literature on markers of V̇O₂ peak, V̇O₂ max, and AT pre- vs post-CPAP using a web-based literature search of PubMed/MEDLINE, Embase, CINAHL, and Cochrane review (CENTRAL) databases. Two independent reviewers screened the articles for data extraction and analysis.

RESULTS

The total search of all the databases returned 470 relevant citations. Following application of eligibility criteria, 6 studies were included in the final meta-analysis for V̇O₂ peak, 2 studies for V̇O₂ max, and five studies for AT. The meta-analysis showed a mean net difference in V̇O₂ peak between pre- and post-CPAP of 2.69 mL·kg^-1·min^-1, P = .02, favoring treatment with CPAP. There was no difference in V̇O₂ max or AT with CPAP treatment (mean net difference 0.66 mL·kg^-1·min^-1 [P = .78] and -144.98 mL·min^-1 [P = .20] respectively).

CONCLUSIONS

There is a paucity of high-quality studies investigating the effect of CPAP on exercise capacity. Our meta-analysis shows that V̇O₂ peak increases following CPAP treatment in patients with OSA, but we did not observe any change in V̇O₂ max or AT. Our findings should be considered preliminary and we recommend further randomized controlled trials to confirm our findings and to clarify the peak and maximum rates of oxygen uptake adaptations with CPAP therapy.

Response of the oxygen uptake efficiency slope to exercise training in patients with chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) patients have poor cardiorespiratory fitness. Although cardiopulmonary exercise testing (CPET) is a universal assessment of cardiorespiratory fitness, values taken at 'peak' effort are strongly influenced by motivation and the choice of test endpoint. The oxygen uptake efficiency slope (OUES) integrates cardiovascular, musculoskeletal, and respiratory function into a single index to provide a more pragmatic and safer alternative to maximal testing. No research has explored whether exercise can improve the OUES in CKD patients.

METHODS

Thirty-two patients with non-dialysis CKD were recruited into a 12-week exercise program consisting of mixed aerobic and resistance training three times a week. CPET was conducted at baseline, and then, following a 6-week control period, at pre- and post-exercise intervention. Direct measurements of oxygen consumption (V̇O2) and ventilatory parameters were collected. The OUES was calculated as the relationship between V̇O2 and the log10 of minute ventilation (V̇E).

RESULTS

No changes were observed in any variable during the control period, although modest increases in V̇O2peak were observed. No meaningful changes were observed as a result of exercise in any cardiorespiratory value obtained. The OUES calculated at 100%, 90%, 75%, and 50% of exercise duration did not change significantly after 12 weeks of exercise training.

CONCLUSION

Our results show that 12 weeks of exercise training had no beneficial effects on the OUES, which supports the modest change observed in V̇O2peak. The lack of change in the OUES and other parameters could indicate a dysfunctional cardiorespiratory response to exercise in patients with CKD, likely mediated by dysfunctional peripheral metabolic mechanisms.