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Kirkman DL, Bohmke N, Carbone S, Garten RS, Rodriguez-Miguelez P, Franco RL, Kidd JM, Abbate A. Exercise intolerance in kidney diseases: physiological contributors and therapeutic strategies. Am J Physiol Renal Physiol 2020; 320:F161-F173. [PMID: 33283641 DOI: 10.1152/ajprenal.00437.2020] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Exertional fatigue, defined as the overwhelming and debilitating sense of sustained exhaustion that impacts the ability to perform activities of daily living, is highly prevalent in chronic kidney disease (CKD) and end-stage renal disease (ESRD). Subjective reports of exertional fatigue are paralleled by objective measurements of exercise intolerance throughout the spectrum of the disease. The prevalence of exercise intolerance is clinically noteworthy, as it leads to increased frailty, worsened quality of life, and an increased risk of mortality. The physiological underpinnings of exercise intolerance are multifaceted and still not fully understood. This review aims to provide a comprehensive outline of the potential physiological contributors, both central and peripheral, to kidney disease-related exercise intolerance and highlight current and prospective interventions to target this symptom. In this review, the CKD-related metabolic derangements, cardiac and pulmonary dysfunction, altered physiological responses to oxygen consumption, vascular derangements, and sarcopenia are discussed in the context of exercise intolerance. Lifestyle interventions to improve exertional fatigue, such as aerobic and resistance exercise training, are discussed, and the lack of dietary interventions to improve exercise tolerance is highlighted. Current and prospective pharmaceutical and nutraceutical strategies to improve exertional fatigue are also broached. An extensive understanding of the pathophysiological mechanisms of exercise intolerance will allow for the development of more targeted therapeutic approached to improve exertional fatigue and health-related quality of life in CKD and ESRD.
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Affiliation(s)
- Danielle L Kirkman
- Department of Kinesiology and Health Sciences, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, Virginia
| | - Natalie Bohmke
- Department of Kinesiology and Health Sciences, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, Virginia
| | - Salvatore Carbone
- Department of Kinesiology and Health Sciences, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, Virginia.,Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Ryan S Garten
- Department of Kinesiology and Health Sciences, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, Virginia
| | - Paula Rodriguez-Miguelez
- Department of Kinesiology and Health Sciences, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, Virginia
| | - Robert L Franco
- Department of Kinesiology and Health Sciences, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, Virginia
| | - Jason M Kidd
- Division of Nephrology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Antonio Abbate
- Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia.,Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia
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Johansen KL, Finkelstein FO, Revicki DA, Gitlin M, Evans C, Mayne TJ. Systematic Review and Meta-analysis of Exercise Tolerance and Physical Functioning in Dialysis Patients Treated With Erythropoiesis-Stimulating Agents. Am J Kidney Dis 2010; 55:535-48. [PMID: 20133033 DOI: 10.1053/j.ajkd.2009.12.018] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2009] [Accepted: 12/08/2009] [Indexed: 11/11/2022]
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Leaf DE, Goldfarb DS. Interpretation and review of health-related quality of life data in CKD patients receiving treatment for anemia. Kidney Int 2008; 75:15-24. [PMID: 18813284 DOI: 10.1038/ki.2008.414] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Recent evidence suggests that targeting higher hemoglobin values with erythropoiesis stimulating agents (ESAs) may lack mortality benefits and may even result in adverse cardiovascular complications when used in chronic kidney disease patients. However, ESAs are frequently reported to result in improvements in health-related quality of life (HRQOL). The purpose of this review is to evaluate the magnitude and nature of ESA-associated improvements in HRQOL, as well as to understand how to interpret the clinical significance of HRQOL data. HRQOL findings should be analyzed not by statistical significance but rather by using a minimal clinically important difference approach, or, alternatively, a distribution-based approach (such as Cohen's effect size). HRQOL domains that are most improved with ESAs relate to physical symptoms, vitality, energy, and performance; domains of social functioning and mental health show modest improvement, whereas the domains of emotional functioning and pain show very little improvement. Additional domains not measured by commonly used instruments (such as the SF-36) that have been shown to improve with ESAs include sleep, cognitive functioning, and sexual functioning. The maximal increase in HRQOL per incremental increase in hemoglobin appears to occur in the range of 10-12 g/dl. Beyond this range, additional normalization of hemoglobin (to 12-14 g/dl) results in continued (albeit blunted) improvements in HRQOL.
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Affiliation(s)
- David E Leaf
- Department of Medicine, New York University School of Medicine, New York, New York, USA
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Diamond PT, Conaway MR, Mody SH, Bhirangi K. Influence of hemoglobin levels on inpatient rehabilitation outcomes after total knee arthroplasty. J Arthroplasty 2006; 21:636-41. [PMID: 16877147 DOI: 10.1016/j.arth.2005.09.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2005] [Accepted: 09/14/2005] [Indexed: 02/01/2023] Open
Abstract
This retrospective study examined the influence of hemoglobin (Hb) on the outcomes of 184 acute inpatient rehabilitation patients admitted to a single university-based inpatient rehabilitation facility after primary total knee arthroplasty between 2001 and 2003. Patient function was measured using the Functional Independence Measure (FIM) instrument. Average length of stay was 9.4 days. Total FIM score increased from 81.5 to 110.8. Mean baseline Hb was 10.5 g/dL. Multivariate analyses demonstrated that a higher Hb at baseline was associated with significantly shorter length of stay (P = .004) and greater FIM efficiency (change in total FIM score/length of stay) (P = .04). Hemoglobin is associated with rehabilitation outcomes after total knee arthroplasty; additional research into the influence of blood management strategies on rehabilitation outcomes is warranted.
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Affiliation(s)
- Paul T Diamond
- Department of Physical Medicine and Rehabilitation, University of Virginia, Charlottesville, Virginia 22908-1004, USA
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Eliopoulos N, Gagnon RF, Francois M, Galipeau J. Erythropoietin delivery by genetically engineered bone marrow stromal cells for correction of anemia in mice with chronic renal failure. J Am Soc Nephrol 2006; 17:1576-84. [PMID: 16672321 DOI: 10.1681/asn.2005101035] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The goal of this research was to develop a strategy to couple stem cell and gene therapy for in vivo delivery of erythropoietin (Epo) for treatment of anemia of ESRD. It was shown previously that autologous bone marrow stromal cells (MSCs) can be genetically engineered to secrete pharmacologic amounts of Epo in normal mice. Therefore, whether anemia in mice with mild to moderate chronic renal failure (CRF) can be improved with Epo gene-modified MSCs (Epo+MSCs) within a subcutaneous implant was examined. A cohort of C57BL/6 mice were rendered anemic by right kidney electrocoagulation and left nephrectomy. In these CRF mice, the hematocrit (Hct) dropped from a prenephrectomy baseline of approximately 55% to 40% after induction of renal failure. MSCs from C57BL/6 donor mice were genetically engineered to secrete murine Epo at a rate of 3 to 4 units of Epo/10(6) cells per 24 h, embedded in a collagen-based matrix, and implanted subcutaneously in anemic CRF mice. It was observed that Hct increased after administration of Epo+MSCs, according to cell dose. Implants of 3 million Epo+MSCs per mouse had no effect on Hct, whereas 10 million led to a supraphysiologic effect. The Hct of CRF mice that received 4.5 or 7.5 million Epo+MSCs rose to a peak 54+/-4.0 or 63+/-5.5%, respectively, at 3 wk after implantation and remained above 48 or 54% for >19 wk. Moreover, mice that had CRF and received Epo+MSCs showed significantly greater swimming exercise capacity. In conclusion, these results demonstrate that subcutaneous implantation of Epo-secreting genetically engineered MSCs can correct anemia that occurs in a murine model of CRF.
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Affiliation(s)
- Nicoletta Eliopoulos
- Lady Davis Institute for Medical Research, McGill University Health Center, and Division of Hematology/Oncology, Jewish General Hospital, 3755 Cote Sainte-Catherine Road, Montreal, Quebec, Canada H3T 1E2
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Callahan LA, Woods KF, Mensah GA, Ramsey LT, Barbeau P, Gutin B. Cardiopulmonary responses to exercise in women with sickle cell anemia. Am J Respir Crit Care Med 2002; 165:1309-16. [PMID: 11991885 DOI: 10.1164/rccm.2002036] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Multiple factors contribute to exercise intolerance in patients with sickle cell anemia, but little information exists regarding the safety of maximal cardiopulmonary exercise testing (CPET) or the mechanisms of exercise limitation in these patients. The purpose of the present study was to examine these issues. Seventeen adult women with sickle cell anemia underwent symptom-limited maximal CPET using cycle ergometry and ramp protocols; blood gases and lactate concentrations were measured every 2 minutes. All patients completed CPET without complications. No patient demonstrated a mechanical ventilatory limitation to exercise or had evidence of myocardial ischemia. However, we observed three pathophysiologic patterns of response to exercise in these patients. Eleven patients had low peak VO2, low anaerobic threshold (AT), gas exchange abnormalities, and high ventilatory reserve; this pattern is consistent with exercise limitation due to pulmonary vascular disease in this patient subgroup. Three patients had low peak VO2, low AT, no gas exchange abnormalities, and a high heart rate reserve, a pattern consistent with peripheral vascular disease and/or a myopathy. The remaining three patients had low peak VO2, low AT, no gas exchange abnormalities, and a low heart rate reserve; this pattern of exercise limitation is best explained by anemia.
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Affiliation(s)
- Leigh A Callahan
- Pulmonary and Critical Care Unit, Department of Medicine, University of Rochester Medical Center, Rochester, New York 14642-8692, USA.
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Diamond PT, Julian DM. Practice trends in the management of low hematocrit in the acute rehabilitation setting. Am J Phys Med Rehabil 2001; 80:816-20. [PMID: 11805452 DOI: 10.1097/00002060-200111000-00005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine current clinical practice regarding the management of anemic patients in the acute rehabilitation setting. DESIGN Ninety-four medical directors of inpatient rehabilitation units were surveyed on their use of transfusion thresholds and human recombinant erythropoietin. Factors affecting their clinical decision making were assessed. RESULTS The majority of physicians responded that they recommend red cell transfusion in patients with a hematocrit <25%. When a history of cardiovascular disease and advanced age was present, more physicians were likely to transfuse at higher hematocrit levels. Forty-six percent of physicians reported recommending the use of human recombinant erythropoietin in anemic patients. Only 30% of respondents classified their clinical management of anemia as evidence based. CONCLUSIONS Clinical practice guidelines should be developed to aid the rehabilitation medicine specialist in the management of anemic patients in the acute rehabilitation setting. Further study of the relationship between hematocrit level, tolerance for therapeutic exercise, and long-term functional outcome is indicated.
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Affiliation(s)
- P T Diamond
- Department of Physical Medicine and Rehabilitation, University of Virginia Health System, Charlottesville, Virginia 22908-1004, USA
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Clark AL, Poole-Wilson PA, Coats AJ. Exercise limitation in chronic heart failure: central role of the periphery. J Am Coll Cardiol 1996; 28:1092-102. [PMID: 8890800 DOI: 10.1016/s0735-1097(96)00323-3] [Citation(s) in RCA: 341] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The symptoms of chronic heart failure (CHF) are predominantly shortness of breath and fatigue during exercise and reduced exercise capacity. Disturbances of central hemodynamic function are no longer considered to be the major determinants of exercise capacity. The two symptoms of fatigue and breathlessness are often considered in isolation. A pulmonary abnormality is usually considered to be the cause of abnormal ventilation, and increased dead space ventilation has come to be accepted as a major cause of the increased ventilation relative to carbon dioxide production seen in CHF. Rather than decreased skeletal muscle perfusion, an intrinsic muscle abnormality is considered to be responsible for fatigue. Another abnormality seen in CHF is persistent sympathetic nervous system activation, which is difficult to explain on the basis of baroreflex activation. There is increasing evidence for the importance of skeletal muscle ergoreceptors or metaboreceptors in CHF. These receptors are sensitive to work performed, and activation results in increased ventilation and sympathetic activation. The ergoreflex appears to be greatly enhanced in CHF. We put forward the "muscle hypothesis" as an explanation for many of the pathophysiologic events in CHF. Impaired skeletal muscle function results in ergoreflex activation. In turn, this causes increased ventilation, thus linking the symptoms of breathlessness and fatigue. Furthermore, ergoreflex stimulation may be responsible for persistent sympathetic activation.
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Affiliation(s)
- A L Clark
- Department of Cardiac Medicine, National Heart and Lung Institute, London, England, United Kingdom
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Clark AL, Volterrani M, Cerquetani E, Ludman P, Swan JW, Poole-Wilson PA, Coats AJ. Relationship between arterial potassium and ventilation during exercise in patients with chronic heart failure. J Card Fail 1995; 1:133-41. [PMID: 9420643 DOI: 10.1016/1071-9164(95)90015-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The mechanisms underlying the increased ventilatory response to exercise seen in patients with chronic heart failure are not clearly understood. Arterial potassium has been suggested as an important ventilatory stimulant. The authors have investigated the arterial potassium response in patients with heart failure. Although arterial potassium rises during exercise, no evidence was found to suggest a greater potassium response in patients with heart failure compared to normal subjects. There was no direct correlation between the rise in ventilation and the rise in arterial potassium. It remains possible that there is an increased sensitivity to arterial potassium in patients with heart failure, but it would need to be three times greater than in normal subjects.
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Affiliation(s)
- A L Clark
- Department of Cardiac Medicine, National Heart and Lung Institute, London, United Kingdom
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