The effects of aerobic exercise on eGFR, blood pressure and VO2peak in patients with chronic kidney disease stages 3-4: A systematic review and meta-analysis

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.

Physical activity and renal outcome in diabetic and non-diabetic patients with chronic kidney disease stage G3b to G5

The association of physical activity with renal outcome and mortality in advanced chronic kidney disease (CKD; i.e., estimated glomerular filtration rate [eGFR] < 45 ml/min/1.73m2) is poorly studied. We examined this association in patients with advanced CKD in Japan. We used the Rapid Assessment of Physical Activity to assess baseline physical activity and classify patients as active or inactive. CKD progression was defined as 40% decline in eGFR, eGFR < 10, or requiring dialysis or transplantation. Among the 1,808 eligible patients, after adjusting for possible confounders, hazard ratios (HRs) for poor renal outcome in the active group were 0.68 (95% CI, 0.44-1.04), 1.09 (0.86-1.38), and 1.01 (0.82-1.25) in CKD stage G3b, G4, and G5, respectively, suggesting a renal benefit of exercise in CKD stage G3b. Adjusted HRs for death were 0.79 (0.40-1.57), 0.55 (0.38-0.80), and 0.75 (0.44-1.26) in stage G3b, G4, and G5, respectively. While the adjusted HRs of death were 0.84 (0.52-1.38) and 0.60 (0.43-0.83) in diabetic and non-diabetic patients, suggesting that exercise may reduce mortality in non-diabetic patients. Our study suggests that exercise is associated with better survival in non-diabetic patients with CKD stage G3b-5, and better renal outcome in diabetic and non-diabetic CKD stage G3b.

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.

Exercise and Cognitive Function in Chronic Kidney Disease: A Systematic Review and Meta-Analysis of Efficacy and Harms

Key Points

Cognitive impairment is common in CKD. Exercise targets multiple risk factors of cognitive decline. Meta-analysis found that exercise had a small but positive effect on cognitive function in CKD, albeit the quality of evidence was low. Further analyses revealed that aerobic exercise was particularly beneficial and that exercise did not substantially increase harms.

Background

People living with CKD are at higher risk of cognitive impairment. Exercise may improve cognitive function. This systematic review and meta-analysis of randomized controlled trials was completed to determine the efficacy and harms of exercise in improving cognitive function in people living with CKD.

Methods

A systematic literature review identified randomized controlled trials of people with any stage of CKD, with an intervention that exercised large-muscle groups, and with a validated outcome measure of cognitive function. First, harms were analyzed. Then a random-effects meta-analysis was completed with subsequent planned subgroup analyses to investigate heterogeneity between CKD stages and treatments; between different exercise types, durations, and intensities; and between different outcome methodologies. Finally, quality of evidence was rated.

Results

Nineteen trials randomized 1160 participants. Harms were reported on 94 occasions in intervention groups versus 83 in control. The primary analysis found that exercise had a small but statistically significant effect on cognition in CKD (effect size=0.22; 95% confidence intervals, 0.00 to 0.44; P = 0.05). However, the quality of evidence was rated as low. Subgroup analyses found that type of exercise moderated the effect on cognition (chi square=7.62; P = 0.02), with positive effects only observed following aerobic exercise (effect size=0.57; 95% confidence interval, 0.21 to 0.93; P = 0.002).

Conclusions

Across the spectrum of CKD, exercise had a small but positive and clinically meaningful effect on cognitive function and did not seem to be harmful. Aerobic exercise was particularly beneficial. However, the results must be interpreted cautiously because of the low quality of evidence. Nevertheless, care teams may choose to recommend aerobic exercise interventions to prevent cognitive decline. Researchers should design unbiased studies to clarify what intensity and duration of exercise is required to maximize efficiency of such exercise interventions.

Exercise intensity and mortality in overweight and obese patients with chronic kidney disease: longitudinal analysis (1999-2016)

BACKGROUND

Chronic kidney disease (CKD) and overweight/obesity are significant global public health issues. Appropriate free-time physical activity (PA) is essential for overweight/obese patients with chronic kidney disease, but specific guidelines are lacking. The present study was conducted to determine the association between PA and all-cause mortality in these patients.

METHODS

Data from 3,434 overweight/obese adults with CKD from the 1999-2016 National Health and Nutrition Examination Surveys were analyzed. Associations between clinical/laboratory findings and PA intensity (moderate and vigorous) were investigated. The all-cause mortality of patients in different PA categories were compared by Kaplan-Meier analysis. Factors associated with all-cause mortality were determined using a Cox proportional hazards model. A restricted cubic spline was employed to obtain a more flexible and detailed representation of the relationship between PA intensity and all-cause mortality, with better predictive capability.

RESULTS

The Kaplan-Meier analysis revealed that greater all-cause mortality was associated with < 10 min/week moderate/vigorous PA (log-rank p < 0.001). A greater survival probability was associated with ≥ 150 min/week vigorous PA or 10-149 min/week moderate PA (log-rank p < 0.001). Age, gender, vigorous PA, smoking status, alcohol consumption, diabetes status, eGFR, serum albumin level, uric acid level, and blood urea nitrogen level were identified as factors associated independently with mortality in the Cox proportional hazards analysis. The restricted cubic splines revealed that these relationships were non-linear (all p < 0.05). Kaplan-Meier analysis of data from patients who engaged in 10-450 min/week moderate/vigorous PA revealed significant differences between the 0-74-min/week and other vigorous PA groups (all log-rank p < 0.001).

CONCLUSIONS

Extended durations of vigorous PA are associated with reduced all-cause mortality in overweight/obese patients with CKD. Clinicians should recommend vigorous free-time PA to these patients, and public health interventions should target this goal to maximize patient health.

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.

The role of exercise training on cardiovascular risk factors and heart disease in patients with chronic kidney disease G3-G5 and G5D: a Clinical Consensus Statement of the European Association of Preventive Cardiology of the ESC and the European Association of Rehabilitation in Chronic Kidney Disease

Cardiovascular (CV) morbidity and mortality is high in patients with chronic kidney disease (CKD). Most patients reveal a high prevalence of CV risk factors such as diabetes or arterial hypertension and many have manifest cardiovascular disease (CVD), such as coronary artery disease and chronic heart failure with an increased risk of clinical events including sudden cardiac death. Diabetes mellitus and hypertension contribute to the development of CKD and the prevalence of CKD is in the range of 20-65% in diabetic and 30-50% in hypertensive patients. Therefore, prevention and optimal treatment of CV risk factors and comorbidities are key strategies to reduce CV risk and improve survival in CKD. Beyond common CV risk factors, patients with CKD are often physically inactive and have low physical function leading to subsequent frailty with muscle fatigue and weakness, sarcopenia and increased risk of falling. Consequently, the economic health burden of CKD is high, requiring feasible strategies to counteract this vicious cycle. Regular physical activity and exercise training (ET) have been shown to be effective in improving risk factors, reducing CVD and reducing frailty and falls. Nonetheless, combining ET and a healthy lifestyle with pharmacological treatment is not frequently applied in clinical practice. For that reason, this Clinical Consensus Statement reviews the current literature and provides evidence-based data regarding the role of ET in reducing CV and overall burden in patients with CKD. The aim is to increase awareness among cardiologists, nephrologists, and healthcare professionals of the potential of exercise therapy in order to encourage implementation of ET in clinical practice, eventually reducing CV risk and disease, as well as reducing frailty in patients with CKD G3-G5D.

Effects of additional physical exercise on the nutritional status and disease progression during the low-protein diet in Chronic Kidney Disease Patients: a systematic review and meta-analysis

Low-protein diet (LPD) is the core of dietary and nutritional therapy for non-dialysis chronic kidney disease (CKD) patients. In addition, physical exercise could prevent and treat various illnesses and chronic diseases. The objective of the study was to search for and appraise evidence on the effect of additional physical exercise on patients' nutritional status and indicators of disease progression when compared with the LPD alone. PubMed Central, Embase, Cochrane, and Web of Knowledge for randomized controlled trials (published between January 1, 1956 and May 17, 2023) were searched. A total of 8698 identified studies, 9 were eligible and were included in our analysis (N = 250 participants). Compared with the LPD alone, additional physical exercise reduced serum creatinine by a mean of -0.21 mg/dL (95% CI -0.39 to -0.03) in CKD patients. Similarly, blood pressure decreased after physical exercise, with systolic blood pressure decreasing by -7.05 mm Hg (95% CI -13.13 to -0.96) and diastolic blood pressure decreasing by -5.31 mm Hg (95% CI -7.99 to -2.62). Subgroup analyses revealed that resistance exercise (RE) was effective in decreasing estimated glomerular filtration rate (eGFR) of -1.71 mL/min per 1.73 m² (95% CI -3.29 to -0.14). In addition, the VO2peak increasing by 2.41 mL/kg/min (95% CI 0.13 to 4.70) when physical exercise was continued for 24 weeks. The above results suggest that the LPD with additional physical exercise care is more beneficial for patients with CKD.

Exercise, Dialysis, and Environment: A Narrative Review in an Ecological Perspective

BACKGROUND

Patient empowerment and environmental sustainability may contribute to creating efficient and resilient healthcare models. Chronic kidney diseases call for a sustainable approach aimed at improving physical function and mental health of patients and possibly contributing to the slowing down of the evolution toward the end stage of renal disease (ESRD) with a reduction of the environmental and economic impact.

SUMMARY

Multidisciplinary interventions should be implemented particularly, at the final stages when patients are exposed to sedentariness, reduced health-related quality of life (HR-QoL), high cardiovascular morbidity and mortality, and the healthcare services to high costs, and participation in environmental pollution. Ecological strategies based on specific nutritional approaches, exercise, and environment should be designed and tested. In particular, the introduction to physical exercise represents a useful replacement therapy to counteract the hazards derived from the sedentary behavior of ESRD patients, with low physical function associated with poor clinical outcomes. A more active and healthy lifestyle, particularly in the natural environment, could impact HR-QoL, mental and physical well-being but also on socialization, with lower anxiety and fatigue stress levels. Otherwise, combining sustainable exercise models into the patient's daily routine can be enhanced by the biophilic design called to reproduce a natural environment in the dialysis center. Finally, the involvement of the personnel and the health professionals in properly managing the exercise interventions and the related factors (location, modality, dose, intensity, and duration) might improve the patients' participation. In particular, ecological programs should be broadly inclusive and aimed to target the lowest performing populations through minimal feasible doses of exercise.

KEY MESSAGES

Moving toward an ecological framework of lifestyle change in the very advanced stages of kidney disease, the potential synergies between environment, diet, and exercise may improve the physical and mental health of the patients and reduce the impact of dialysis.

Application of exercise therapy in patients with chronic kidney disease-induced muscle atrophy: a scoping review

BACKGROUND

The prevalence of muscle atrophy in patients suffering from chronic kidney disease (CKD) presents a significant challenge to healthcare providers, necessitating innovative approaches to management and care. Against this backdrop, this study embarks on a comprehensive review of literature concerning the application of exercise interventions in the nursing care of these patients. Such interventions are critical in addressing the debilitating effects of the condition, which include progressive loss of muscle mass and strength, adversely affecting patient mobility, quality of life, and overall survival. This review aims to identify the specific exercise modalities, contents, outcome indicators, and application effects associated with this intervention, in the context of the complex interplay of metabolic, inflammatory, and hormonal factors contributing to muscle wasting in CKD patients. By examining the efficacy of various exercise interventions, this study seeks to elucidate optimal strategies for mitigating the impact of CKD-induced muscle atrophy, thereby informing clinical practices and improving patient outcomes.

METHODS

According to the method of a scoping review, nine databases (Cochrane, PubMed, EMBASE, Web of Science, ProQuest, Ovid, CNKI, Wanfang Data, and VIP) were searched until September 28, 2023. The included literature was screened, summarized, and analyzed.

RESULTS

A total of 20 pieces of literature were included. Some types include aerobic exercise, resistance exercise, and aerobic combined resistance exercise. The exercise intensity primarily falls within the mild to moderate range, with a recommended frequency of 2 - 3 times a week, lasting 30 - 60 min each time. The types of outcomes encompassed in this study include body composition, functional testing, strength measurements, laboratory examinations, cardiopulmonary function assessments, and patient-reported outcomes. To varying degrees, exercise intervention positively impacts the subjects' physical activity ability, body composition, and skeletal muscle status. Currently, resistance training is the primary type of intervention used for preventing and treating CKD patients induced by muscle atrophy.

CONCLUSION

Exercise intervention can improve muscle strength, physical function, and quality of life in patients with CKD muscle atrophy. Therefore, patients should be fully informed of the effect of exercise intervention in the treatment of chronic kidney disease-induced muscle atrophy in future, so as to promote the standardized implementation of exercise intervention.

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.

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.

Benefits of Cardiac Rehabilitation in Cardio-Renal Patients With Heart Failure With Reduced Ejection Fraction

PURPOSE

Chronic kidney disease (CKD) is common in heart failure (HF). Chronic kidney disease often worsens the prognosis and impairs the management of patients with HF. Chronic kidney disease is frequently accompanied by sarcopenia, which limits the benefits of cardiac rehabilitation (CR). The aim of this study was to evaluate the impact of CR on cardiorespiratory fitness in HF patients with reduced ejection fraction (HFrEF) according to the CKD stage.

METHODS

We conducted a retrospective study including 567 consecutive patients with HFrEF, who underwent a 4-wk CR program, and who were evaluated by cardiorespiratory exercise test before and after the program. Patients were stratified according to their estimated glomerular filtration rate (eGFR). We performed multivariate analysis looking for factors associated with an improvement of 10% in peak oxygen uptake (V˙ o2peak ).

RESULTS

Thirty-eight percent of patients had eGFR <60 mL/min/1.73m². With decreasing eGFR, we observed deterioration in V˙ o2peak , first ventilatory threshold (VT1) and workload and an increase in brain natriuretic peptide levels at baseline. After CR, there was an improvement in V˙ O2peak (15.3 vs 17.8 mL/kg/min, P < .001), VT1 (10.5 vs 12.4 mL/kg/min, P < .001), workload (77 vs 94 W, P < .001), and brain natriuretic peptide (688 vs 488 pg/mL, P < .001). These improvements were statistically significant for all stages of CKD. In a multivariate analysis predicting factors associated with V˙ o2peak improvement, renal function did not interfere with results.

CONCLUSIONS

Cardiac rehabilitation is beneficial in patients with HFrEF with CKD regardless of CKD stage. The presence of CKD should not prevent the prescription of CR in patients with HFrEF.

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.

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 Moderating Role of Health Variables on the Association between Physical Exercise and Quality of Life in Patients with End-Stage Renal Disease

Scientific evidence demonstrates the positive impact that physical exercise has on the quality of life (QOL) of patients with chronic kidney disease (CKD). However, no study has proposed a model investigating the effect physical exercise has on the QOL of end-stage renal disease (ESRD) patients, considering the most frequent associated diseases (diabetes/hypertension). The objectives were (1) to explore the relationship between physical exercise and the QOL of adults with ESRD, and (2) to examine the moderating and/or mediating role of relevant patient variables. This non-interventional study utilized an ex post facto retrospective data analysis design with a sample of 310 patients with ESRD through two validated questionnaires. The dependent variables were the QOL scale (KDQOL-SF), and the physical function dimension (EFFISICA). The independent variables were the regular practice of intense physical activity (DEPINTE) and the daily time (in hours) the patient is in a sedentary attitude (TiParado). The moderating variables were the clinical situation and associated diseases. The mediator variable used was the body mass index. Bivariate and multiple regression analyses were conducted. Findings suggest implementing intense physical activity in transplant recipients and programmes to avoid sedentary lifestyles in dialysis patients have a positive effect in the QOL of ESRD patients.

Neurocirculatory regulation and adaptations to exercise in chronic kidney disease

Chronic kidney disease (CKD) is characterized by pronounced exercise intolerance and exaggerated blood pressure reactivity during exercise. Classic mechanisms of exercise intolerance in CKD have been extensively described previously and include uremic myopathy, chronic inflammation, malnutrition, and anemia. We contend that these classic mechanisms only partially explain the exercise intolerance experienced in CKD and that alterations in cardiovascular and autonomic regulation also play a key contributing role. The purpose of this review is to examine the physiological factors that contribute to neurocirculatory dysregulation during exercise and discuss the adaptations that result from regular exercise training in CKD. Key neurocirculatory mechanisms contributing to exercise intolerance in CKD include augmentation of the exercise pressor reflex, aberrations in neurocirculatory control, and increased neurovascular transduction. In addition, we highlight how some contributing factors may be improved through exercise training, with a specific focus on the sympathetic nervous system. Important areas for future work include understanding how the exercise prescription may best be optimized in CKD and how the beneficial effects of exercise training may extend to the brain.

Management of Type 2 Diabetic Kidney Disease in 2022: A Narrative Review for Specialists and Primary Care

Purpose of review

Kidney disease is present in almost half of Canadian patients with type 2 diabetes (T2D), and it is also the most common first cardiorenal manifestation of T2D. Despite clear guidelines for testing, opportunities are being missed to identify kidney diseases, and many Canadians are therefore not receiving the best available treatments. This has become even more important given recent clinical trials demonstrating improvements in both kidney and cardiovascular (CV) endpoints with sodium-glucose cotransporter 2 (SGLT2) inhibitors and a nonsteroidal mineralocorticoid receptor antagonist, finerenone. The goal of this document is to provide a narrative review of the current evidence for the treatment of diabetic kidney disease (DKD) that supports this new standard of care and to provide practice points.

Sources of information

An expert panel of Canadian clinicians was assembled, including 9 nephrologists, an endocrinologist, and a primary care practitioner. The information the authors used for this review consisted of published clinical trials and guidelines, selected by the authors based on their assessment of their relevance to the questions being answered.

Methods

Panelists met virtually to discuss potential questions to be answered in the review and agreed on 10 key questions. Two panel members volunteered as co-leads to write the summaries and practice points for each of the identified questions. Summaries and practice points were distributed to the entire author list by email. Through 2 rounds of online voting, a second virtual meeting, and subsequent email correspondence, the authors reached consensus on the contents of the review, including all the practice points.

Key findings

It is critical that DKD be identified as early as possible in the course of the disease to optimally prevent disease progression and associated complications. Patients with diabetes should be routinely screened for DKD with assessments of both urinary albumin and kidney function. Treatment decisions should be individualized based on the risks and benefits, patients' needs and preferences, medication access and cost, and the degree of glucose lowering needed. Patients with DKD should be treated to achieve targets for A1C and blood pressure. Renin-angiotensin-aldosterone system blockade and treatment with SGLT2 inhibitors are also key components of the standard of care to reduce the risk of kidney and CV events for these patients. Finerenone should also be considered to further reduce the risk of CV events and chronic kidney disease progression. Education of patients with diabetes prescribed SGLT2 inhibitors and/or finerenone is an important component of treatment.

Limitations

No formal guideline process was used. The practice points are not graded and are not intended to be viewed as having the weight of a clinical practice guideline or formal consensus statement. However, most practice points are well aligned with current clinical practice guidelines.

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.

The effect of regular aerobic exercise on renal function in patients with CKD: A systematic review and meta-analysis

Objective: To evaluate the effect of regular aerobic exercise on the improvement of renal function in patients with chronic kidney disease through meta-analysis and to provide targeted exercise recommendations for patients with CKD. Methods: PubMed, Web of Science, EBSCO, China National Knowledge Infrastructure (CNKI), and other databases were searched, and randomized controlled trials on the effects of regular aerobic exercise on renal function-related indexes in patients with CKD were collected according to the inclusion and exclusion criteria. The methodological quality of the included literature was evaluated using the Cochrane evaluation tool second generation, and statistical analysis was performed using R analysis software. Results: A total of 12 randomized controlled trials (RCTs) with a total of patients with CKD were included, and the results of the meta-analysis showed that regular aerobic exercise significantly improved the estimated glomerular filtration rate SMD = 0.65, 95% CI [0.30, 1.00], serum creatinine SMD = -0.63, 95% CI [-0.86, -0.40], 24-h urine protein volume in patients with CKD SMD = -0.41, 95% CI [-0.70, -0.11], and serum urea nitrogen SMD = -0.66, 95% CI [-1.20, -0.12]. Single exercise session longer than 30 min significantly improved the estimated glomerular filtration rate in CKD patients (p < 0.01), and walking and running as exercise modalities significantly improved CKD patients' SCr levels were significantly improved by walking and running as exercise modalities (p < 0.05), and the improvement effect was not significant when cycling was selected as an exercise modality. Conclusion: Regular aerobic exercise has a significant effect on the estimated glomerular filtration rate, serum creatinine, 24-h urine protein amount, and blood urea nitrogen in CKD patients. Aerobic exercise with a single exercise duration longer than 30 min has a more significant effect on the estimated glomerular filtration rate, and aerobic exercise by walking or running can more effectively improve the serum creatinine in CKD patients.

Therapeutic effects of exercise interventions for patients with chronic kidney disease: an umbrella review of systematic reviews and meta-analyses

OBJECTIVE

To conduct an overview of meta-analyses evaluating the impact of exercise interventions on improving health outcomes in patients with chronic kidney disease (CKD).

DESIGN

An umbrella review of systematic review and meta-analyses of intervention trials was performed.

DATA SOURCES

PubMed, Web of Science, Embase and the Cochrane Database of Systematic Reviews were searched from inception to 9 March 2021 for relevant articles.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Eligible meta-analyses compared the effects of usual care with and without exercise in patients with CKD. Health outcomes included those related to cardiovascular risk factors, physical fitness, dialysis-related symptoms, dialysis adequacy and health-related quality of life. Systematic reviews and meta-analyses that included fewer than 3 RCTs or fewer than 100 participants were excluded from the analysis.

RESULTS

A total of 31 eligible systematic reviews and meta-analyses were included that assessed 120 outcomes. For physical fitness, there was a moderate effect size for cardiorespiratory fitness, muscle strength and body composition and small effect size for muscle endurance. The effect sizes for cardiovascular risk factors, dialysis-related symptoms and health-related quality of life outcomes were small. According to the Grading of Recommendations Assessment, Development and Evaluation framework, most outcomes were low or very low quality.

CONCLUSION

Exercise appears to be a safe way to affect concomitant cardiovascular risk factors, such as blood pressure, improve physical fitness and health-related quality of life and reduce dialysis-related symptoms in patients with CKD.

PROSPERO REGISTRATION NUMBER

CRD42020223591.

The moderate-intensity continuous exercise maintains renal blood flow and does not impair the renal function

Exercise is restricted for individuals with reduced renal function because exercising reduces blood flow to the kidneys. Safe and effective exercise programs for individuals with reduced renal function have not yet been developed. We previously examined the relationship between exercise intensity and renal blood flow (RBF), revealing that moderate-intensity exercise did not reduce RBF. Determining the effects of exercise duration on RBF may have valuable clinical applications. The current study examined the effects of a single bout of continuous exercise at lactate threshold (LT) intensity on renal hemodynamics. Eight adult males participated in this study. Participants underwent 30 min of aerobic exercise at LT intensity using a cycle ergometer. Evaluation of renal hemodynamics was performed before and after exercise, in the recovery phase using ultrasound echo. Furthermore, blood and urine samplings were conducted before and after exercise, in the recovery phase. Compared with resting, RBF was not significantly changed immediately after continuous exercise (319 ± 102 vs. 308 ± 79 ml/min; p = 0.976) and exhibited no significant changes in the recovery phase. Moreover, urinary kidney injury molecule-1 (uKIM-1) level exhibited no significant change immediately after continuous exercise (0.52 ± 0.20 vs. 0.46 ± 0.27 μg/g creatinine; p = 0.447). In addition, the results revealed no significant change in urinary uKIM-1 in 60-min after exercise. Other renal injury biomarkers exhibited a similar pattern. These findings indicate that a single bout of moderate-intensity continuous exercise maintains RBF and does not induce renal injury.

Physical exercise and peritoneal dialysis: An area yet to be explored

Health-related quality of life (HRQoL) of patients suffering from chronic kidney disease (CKD) is profoundly impaired by their frailty, disability and decreased physical capacity. Especially among older patients, a high prevalence of low physical activity levels and reduced functional performance has been reported. Physical exercise training has been shown to have a beneficial impact, counteracting these same hazardous consequences of inactivity and sedentarism both on CKD and end-stage kidney disease (ESKD) patients on hemodialysis (HD) treatment. The evidence-based knowledge on the effects of physical exercise on ESKD patients undergoing Peritoneal Dialysis (PD) treatment is scarce, even though this is a continually growing population that shares the same risk factors and desired clinical outcomes as the previously mentioned groups of patients. Further investigation will be necessary to clarify whether this exercise-based approach may be suitable for the PD population. This paper's purpose is to review the available literature, including randomized controlled trials, reviews and meta-analysis results that assessed the impact of physical exercise on patients under PD treatment bearing in mind their HRQoL, physical functioning and cardiovascular parameters. Furthermore, it aims to evaluate the perceived significant barriers and limitations of the PD population in what concerns physical exercise practice and how nephrologists should address them.

Effect of a 3-Year Lifestyle Intervention in Patients with Chronic Kidney Disease: A Randomized Clinical Trial

BACKGROUND

Supervised lifestyle interventions have the potential to significantly improve physical activity and fitness in patients with CKD.

METHODS

To assess the efficacy of a lifestyle intervention in patients with CKD to improve cardiorespiratory fitness and exercise capacity over 36 months, we conducted a randomized clinical trial, enrolling 160 patients with stage 3-4 CKD, with 81 randomized to usual care and 79 to a 3-year lifestyle intervention. The lifestyle intervention comprised care from a multidisciplinary team, including a nephrologist, nurse practitioner, exercise physiologist, dietitian, diabetes educator, psychologist, and social worker. The exercise training component consisted of an 8-week individualized and supervised gym-based exercise intervention followed by 34 months of a predominantly home-based program. Self-reported physical activity (metabolic equivalent of tasks [METs] minutes per week), cardiorespiratory fitness (peak O₂ consumption [VO_2peak]), exercise capacity (maximum METs and 6-minute walk distance) and neuromuscular fitness (grip strength and get-up-and-go test time) were evaluated at 12, 24, and 36 months.

RESULTS

The intervention increased the percentage of patients meeting physical activity guideline targets of 500 MET min/wk from 29% at baseline to 63% at 3 years. At 12 months, both VO_2peak and METs increased significantly in the lifestyle intervention group by 9.7% and 30%, respectively, without change in the usual care group. Thereafter, VO_2peak declined to near baseline levels, whereas METs remained elevated in the lifestyle intervention group at 24 and 36 months. After 3 years, the intervention had increased the 6-minute walk distance and blunted declines in the get-up-and-go test time.

CONCLUSIONS

A 3-year lifestyle intervention doubled the percentage of CKD patients meeting physical activity guidelines, improved exercise capacity, and ameliorated losses in neuromuscular and cardiorespiratory fitness.

Physical Exercise in People with Chronic Kidney Disease-Practices and Perception of the Knowledge of Health Professionals and Physical Activity and Sport Science Professionals about Their Prescription

There is evidence on the need to include physical exercise as a treatment for diseases. A large number of professionals are involved in this, but it is not known how physical exercise is prescribed and which professionals are involved. This research has two objectives: (a) to find out the current practices in Spain regarding the prescription of physical exercise in patients with Chronic Kidney Disease (CKD) and (b) to analyse the perception that different health and physical activity professionals have of their knowledge to prescribe of physical exercise in the treatment of CKD. This is an empirical research with an ex post facto retrospective analysis of the information in a descriptive and correlational way. A total of 692 health and sports professionals participated. A questionnaire validated by a committee of experts was administered. Descriptive analyses were carried out and the differences in the study variables were analysed using Chi-square tests and one-factor Analysis of Variance. From the results obtained, we conclude there is a need to develop specific training programmes in the field of physical exercise for health professionals, as well as the establishment of multiprofessional teams for the prescription of physical exercise in CKD treatment, including physical exercise professionals (Cafyde).

Sarcopenia in Chronic Kidney Disease: A Scoping Review of Prevalence, Risk Factors, Association with Outcomes, and Treatment

Sarcopenia, a condition characterized by loss of skeletal muscle mass and function, has important clinical ramifications. We aimed to map the existing literature about prevalence, risk factors, associated adverse outcomes, and treatment of sarcopenia in individuals with chronic kidney disease (CKD). A scoping review of the literature was conducted to identify relevant articles published from databases' inception to September 2019. Individuals with CKD, regardless of their disease stage and their comorbidities, were included. Only studies with sarcopenia diagnosed using both muscle mass and function, based on published consensus definitions, were included. For studies on treatment, only randomized controlled trials with at least one sarcopenia parameter as an outcome were included. Our search yielded 1318 articles, of which 60 from were eligible for this review. The prevalence of sarcopenia ranged from 4 to 42% according to the definition used, population studied, and the disease stage. Several risk factors for sarcopenia were identified including age, male gender, low BMI, malnutrition, and high inflammatory status. Sarcopenia was found to be associated with several adverse outcomes, including disabilities, hospitalizations, and mortality. In CKD subjects, several therapeutic interventions have been assessed in randomized controlled trial with a muscle mass, strength, or function endpoint, however, studies focusing on sarcopenic CKD individuals are lacking. The key interventions in the prevention and treatment of sarcopenia in CKD seem to be aerobic and resistance exercises along with nutritional interventions. Whether these interventions are effective to treat sarcopenia and prevent clinical consequences in this population remains to be fully determined.

Cardiorespiratory Fitness Associates with Blood Pressure and Metabolic Health of Children-The Arkansas Active Kids Study

INTRODUCTION

High blood pressure (HBP) in children causes preclinical damage to the heart and accelerates atherosclerosis. Current pharmacological treatments have limited ability to prevent end-organ damage, particularly that of the kidneys. A contrasting element between adult versus pediatric HPB treatment is the emphasis in adults on exercise regimens that target increments in cardiorespiratory fitness (CRF; peak oxygen consumption [V˙O2peak]). The aim of this study was to evaluate the association of CRF with blood pressure percentiles and blood pressure status in children with normal and excessive adiposity (NA vs EA). An exploratory aim was to measure associations of CRF with (a) other cardiovascular disease risk factors commonly found in children with HBP and (b) kidney function.

METHODS

Children (n = 211) attended one study visit. CRF was measured using an incremental bike test and body composition by dual-energy x-ray absorptiometry. Fat-free mass (FFM) index was calculated as kilograms of FFM per square meter. Multiple logistic and linear regression analyses were used to model the probability of HBP and other variables of interest (plasma lipids, HOMA2-IR, alanine aminotransferase, and estimated glomerular filtration rate) against V˙O2peak.

RESULTS

CRF interacted with adiposity status in predicting the probability of HBP. Each additional milliliter per minute per FFM index in V˙O2peak decreased the odds of HBP by 8% in the EA group only (odds ratio = 0.92, 95% confidence interval = 0.87-0.99). Systolic and diastolic blood pressure percentiles decreased, and estimated glomerular filtration rate increased with increasing CRF in both adiposity-level groups. HOMA2-IR and alanine aminotransferase decreased with increasing CRF in children with EA only.

CONCLUSIONS

Higher CRF associated with decreased probability of clinical HBP, lower insulin resistance, and improved liver function in children with EA. Yet blood pressure percentiles and kidney function improved with increasing CRF irrespective of adiposity status.

Effectiveness and safety of rehabilitation on minimal change nephrotic syndrome in remission for elderly patients with low activity of daily living: a case report

There are few reports on the rehabilitation of elderly patients with minimal change nephrotic syndrome (MCNS). The purpose of this case study was to evaluate the efficacy and safety of rehabilitation for an elderly patient with MCNS in remission. The patient was an 86-year-old woman. She was admitted to the hospital with a diagnosis of MCNS, and steroid treatment was initiated. She was weaned from dialysis 2 weeks later; however, her activities of daily living (ADL) decreased, and she developed disuse syndrome. After rehabilitation, the patient's ADL, maximum hand grip strength, and gait function improved. There was no recurrence of weight gain or increased proteinuria during rehabilitation, but the estimated glomerular filtration rate decreased. This case suggests that rehabilitation for elderly patients with MCNS in remission can be effective for physical and ADL functions without relapse of MCNS. The effect of exercise therapy on the relationship between exercise therapy and renal function needs to be further investigated by collecting more cases.

Physical exercise and peritoneal dialysis: An area yet to be explored

Health-related quality of life (HRQoL) of patients suffering from chronic kidney disease (CKD) is profoundly impaired by their frailty, disability and decreased physical capacity. Especially among older patients, a high prevalence of low physical activity levels and reduced functional performance has been reported. Physical exercise training has been shown to have a beneficial impact, counteracting these same hazardous consequences of inactivity and sedentarism both on CKD and end-stage kidney disease (ESKD) patients on hemodialysis (HD) treatment. The evidence-based knowledge on the effects of physical exercise on ESKD patients undergoing Peritoneal Dialysis (PD) treatment is scarce, even though this is a continually growing population that shares the same risk factors and desired clinical outcomes as the previously mentioned groups of patients. Further investigation will be necessary to clarify whether this exercise-based approach may be suitable for the PD population. This paper's purpose is to review the available literature, including randomized controlled trials, reviews and meta-analysis results that assessed the impact of physical exercise on patients under PD treatment bearing in mind their HRQoL, physical functioning and cardiovascular parameters. Furthermore, it aims to evaluate the perceived significant barriers and limitations of the PD population in what concerns physical exercise practice and how nephrologists should address them.

Home-Based Exercise for People With Chronic Kidney Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Exercise performed at home could be a useful therapy for people with chronic kidney disease. This systematic review and meta-analysis aimed at describing the characteristics, main findings, methodological quality, and adherence rate reported in the existent randomized controlled trials that have provided information regarding the impact of home-based exercise programs on people with chronic kidney disease.

METHODS

Electronic databases (MEDLINE/PubMed, SPORTDiscus, Scopus, and CENTRAL) were searched up to April 2021, using the keywords: "Exercise"; "Home"; "Kidney Disease." Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was adopted. Jadad scale and Cochrane's tool were used to assess the methodological quality and risk of bias.

RESULTS

Out of the 14 studies finally selected, 11 were included in the meta-analysis and most presented high methodological quality. The meta-analysis showed significant effects of home-based exercise on fitness and quality of life, but a little impact on renal function. Although exercise performed at home was mostly feasible and safe, adherence was not high and a considerable number of dropouts were observed.

CONCLUSION

Home-based exercise has positive effects on the fitness' level and on the quality of life on people with chronic kidney disease. Future studies are needed to identify whether exercise performed at home is a better physical therapy option than center-based exercise.

Effects of exercise on markers of inflammation and indicators of nutrition in patients with chronic kidney disease: a systematic review and meta-analysis

PURPOSE

This meta-analysis aimed to reveal the effects of exercise training on markers of inflammation and indicators of nutrition in non-dialysis-dependent patients with chronic kidney disease (NDD-CKD).

METHODS

We searched the MEDLINE, EMBASE, CENTRAL, Web of Science, CINAHL, CNKI, WANFANE, VIP, and CBM databases, from their inception up to October 2020 to identify randomized controlled trials that examined the effects of exercise training on inflammation and nutrition in NDD-CKD patients. A total of 16 trials, comprising 724 patients, were included in the analysis.

RESULTS

The BMI (P = 0.005) and waist circumference (P = 0.004) decreased significantly after exercise training in NDD-CKD patients. Similarly, IL-6 (P = 0.03) decreased after exercise training in NDD-CKD patients. However, serum albumin level, body fat, CRP and hs-CRP were not different between patients who received exercise training and those who received usual care. Furthermore, BMI (P = 0.009), body weight (P = 0.009), and waist circumference (P = 0.010) were decreased in overweight patients (BMI ≧ 25 kg/m²). Moreover, BMI (P = 0.003), body weight (P = 0.005), and waist circumference (P = 0.007) reduced when the length of intervention exceeded 48 weeks. Subgroup analyses revealed no significant alteration of serum albumin, body fat, CRP, or hs-CRP, when studies were divided based on BMI or intervention duration.

CONCLUSION

Overall, these findings suggest that exercise training may improve inflammation status in NDD-CKD patients, and enhance weight loss in obese adult CKD patients. Registration number: INPLASY2020100025.

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

PURPOSE

Reviewing systematically the randomized controlled trials (RCTs) that evaluated aerobic exercisealone vs. usual care in exercise tolerance, functional capacity, and quality of life (QoL) in patients withpre-dialysis.

METHODS

Searches in the MEDLINE, Cochrane CENTRAL, EMBASE, PEDro, and LILACS databases untilFebruary 2021 included RCTs that evaluated the effects of aerobic exercise on peak VO₂, functional capacity,lower limb muscle strength, and QoL. The random effect meta-analysis model was used andreported as mean difference (MD) and 95% confidence interval (CI), risk of bias through RoB2.0 and thequality of evidence by GRADE.

RESULTS

10 RCTs, with 365 patients. Aerobic exercise increased 2.07 ml/kg/min (95% CI = 1.16 to 2.98; I2= 24%, QoE moderate) at peak VO₂; 77.78m (95% CI= 33.27 to 122.30; I2= 44.5%, QoE moderate) in the 6MWT and 7.65 repetitions (95% CI= 5.73 to 9.58; I2= 0 %; QoE moderate) in STS-30 versus usual care. In QoL, studies reported improvements in the questionnaire scores. Eu.² = 24%, QoE moderado) no pico de VO₂; 77,78 m (IC95% = 33,27-122,30; Eu.² = 44,5%, QoE moderado) nas repetições 6MWT e 7,65 (IC95% = 5,73-9,58; Eu.² = 0%; QoE moderado) em STS-30".

CONCLUSION

Aerobic exercise increases VO₂ peak, functional capacity and lower limb muscle strength in patients with pre-dialysis. Effects on QoL appear to be beneficial.IMPLICATIONS FOR REHABILITATIONAerobic exercise should be encouraged in the rehabilitation of patients at any stage of chronic kidney disease.Aerobic exercise promotes improved exercise tolerance, functional capacity, and muscle strength of the lower limbs.There is some evidence to show it is beneficial to improve the quality of life.

Deficits in the Skeletal Muscle Transcriptome and Mitochondrial Coupling in Progressive Diabetes-Induced CKD Relate to Functional Decline

Two-thirds of people with type 2 diabetes mellitus (T2DM) have or will develop chronic kidney disease (CKD), which is characterized by rapid renal decline that, together with superimposed T2DM-related metabolic sequelae, synergistically promotes early frailty and mobility deficits that increase the risk of mortality. Distinguishing the mechanisms linking renal decline to mobility deficits in CKD progression and/or increasing severity in T2DM is instrumental both in identifying those at high risk for functional decline and in formulating effective treatment strategies to prevent renal failure. While evidence suggests that skeletal muscle energetics may relate to the development of these comorbidities in advanced CKD, this has never been assessed across the spectrum of CKD progression, especially in T2DM-induced CKD. Here, using next-generation sequencing, we first report significant downregulation in transcriptional networks governing oxidative phosphorylation, coupled electron transport, electron transport chain (ETC) complex assembly, and mitochondrial organization in both middle- and late-stage CKD in T2DM. Furthermore, muscle mitochondrial coupling is impaired as early as stage 3 CKD, with additional deficits in ETC respiration, enzymatic activity, and increased redox leak. Moreover, mitochondrial ETC function and coupling strongly relate to muscle performance and physical function. Our results indicate that T2DM-induced CKD progression impairs physical function, with implications for altered metabolic transcriptional networks and mitochondrial functional deficits as primary mechanistic factors early in CKD progression in T2DM.

Renal Rehabilitation: Exercise Intervention and Nutritional Support in Dialysis Patients

With the growing number of dialysis patients with frailty, the concept of renal rehabilitation, including exercise intervention and nutrition programs for patients with chronic kidney disease (CKD), has become popular recently. Renal rehabilitation is a comprehensive multidisciplinary program for CKD patients that is led by doctors, rehabilitation therapists, diet nutritionists, nursing specialists, social workers, pharmacists, and therapists. Many observational studies have observed better outcomes in CKD patients with more physical activity. Furthermore, recent systematic reviews have shown the beneficial effects of exercise intervention on exercise tolerance, physical ability, and quality of life in dialysis patients, though the beneficial effect on overall mortality remains unclear. Nutritional support is also fundamental to renal rehabilitation. There are various causes of skeletal muscle loss in CKD patients. To prevent muscle protein catabolism, in addition to exercise, a sufficient supply of energy, including carbohydrates, protein, iron, and vitamins, is needed. Because of decreased digestive function and energy loss due to dialysis treatment, dialysis patients are recommended to ingest 1.2-fold more protein than the regular population. Motivating patients to join in activities is also an important part of renal rehabilitation. It is essential for us to recognize the importance of renal rehabilitation to maximize patient satisfaction.

Assessment of Exercise Intolerance in Patients with Pre-Dialysis CKD with Cardiopulmonary Function Testing: Translation to Everyday Practice

BACKGROUND

Chronic kidney disease (CKD) is often characterized by increased prevalence of cardiovascular risk factors and increased incidence of cardiovascular events and death. Reduced cardiovascular reserve and exercise intolerance are common in patients with CKD and are associated with adverse outcomes.

SUMMARY

The gold standard for identifying exercise limitation is cardiopulmonary exercise testing (CPET). CPET provides an integrative evaluation of cardiovascular, pulmonary, hematopoietic, neuropsychological, and metabolic function during maximal or submaximal exercise. It is useful in clinical setting for differentiation of the causes of exercise intolerance, risk stratification, and assessment of response to relevant treatments. A number of recent studies have used CPET in patients with pre-dialysis CKD, aiming to assess the cardiovascular reserve of these individuals, as well as the effect of interventions such as exercise training programs on their functional capacity. This review provides an in-depth description of CPET methodology and an overview of studies that utilized CPET technology to assess cardiovascular reserve in patients with pre-dialysis CKD. Key Messages: CPET can delineate multisystem changes and offer comprehensive phenotyping of factors determining overall cardiovascular risk. Potential clinical applications of CPET in CKD patients range from objective diagnosis of exercise intolerance to preoperative and long-term risk stratification and providing intermediate endpoints for clinical trials. Future studies should delineate the association of CPET indexes, with cardiovascular and respiratory alterations and hard outcomes in CKD patients, to enhance its diagnostic and prognostic utility in this population.

Exercise training in chronic kidney disease-effects, expectations and adherence

There is increasing evidence showing the health benefits of physical activity, such as better survival and possibly even a slower decline in kidney function, in people with chronic kidney disease (CKD). There is convincing evidence that exercise training improves physical function measured as aerobic capacity, muscle endurance strength and balance at all ages and all stages of CKD. In fact, long-term adherence to well-designed and adequately monitored exercise training programmes is high. In general, patients express interest in exercise training and are motivated to improve their physical function and health. A growing number of nephrologists regard physical activity and exercise training as beneficial to patients with CKD. However, many feel that they do not have the knowledge to prescribe exercise training and suppose that patients are not interested. Patients state that support from healthcare professionals is crucial to motivate them to participate in exercise training programmes and overcome medical, physical and psychological barriers such as frailty, fatigue, anxiety and fear. Equally important is the provision of funding by healthcare providers to ensure adequate prescription and follow-up by trained exercise physiologists for this important non-pharmacological treatment.

Efficacy of aerobic exercise on the cardiometabolic and renal outcomes in patients with chronic kidney disease: a systematic review of randomized controlled trials

BACKGROUND

Several randomized controlled trials (RCTs) have demonstrated the cardiometabolic effects of aerobic exercise in the general population and in patients with cardiovascular diseases. However, the efficacy of aerobic exercise in patients with chronic kidney disease (CKD) remains to be elucidated.

METHODS

RCTs comparing aerobic exercise with no aerobic exercise in patients with CKD not requiring kidney replacement therapy were identified through PubMed using RobotAnalyst, a web-based software system that combines text-mining and machine learning algorithms for organizing references. Cardiometabolic and renal outcomes of interest included body mass index (BMI); systolic blood pressure (SBP); hemoglobin A1c (HbA1c), total cholesterol (TCHO), low- and high- density lipoprotein cholesterol (LDLC and HDLC, respectively), and urinary protein (UP) levels/concentration; peak oxygen uptake (Vo2peak); and glomerular filtration rate (GFR) at the end of the follow-up period. The standardized mean difference (SMD) of each outcome was estimated using the DerSimonian-Laird random-effect model with inverse-variance weighting.

RESULTS

A total of 15 trials, including 622 patients, were included. Their follow-up periods were 3-4, 6-12, and > 12-months in 7 (46.7%), 7 (46.7%), and 1 (6.7%) trial(s), respectively. Meta-analyses showed that aerobic exercise significantly decreased BMI (SMD, -0.19 [95% confidence interval, -0.38, -0.00]) and SBP (-0.75 [-1.24, -0.26]) and increased Vo2peak (0.54 [0.29, 0.78]); however, no significant association was observed in HbA1c, TCHO, HDLC, LDLC, GFR, and UP. Meta-regression models suggested that aerobic exercise was more likely to improve Vo2peak in patients with younger age, no diabetes, and lower BMI.

CONCLUSION

Aerobic exercise of 3-12 months' duration improved obesity, high blood pressure, and low exercise capacity in overweight/obese patients with CKD, but it had no significant effect on GFR and proteinuria. Well-designed large RCTs with a longer follow-up period are needed to evaluate the efficacy of aerobic exercise in patients with CKD.

The case for early identification and intervention of chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Chronic kidney disease (CKD) causes substantial global morbidity and increases cardiovascular and all-cause mortality. Unlike other chronic diseases with established strategies for screening, there has been no consensus on whether health systems and governments should prioritize early identification and intervention for CKD. Guidelines on evaluating and managing early CKD are available but have not been universally adopted in the absence of incentives or quality measures for prioritizing CKD care. The burden of CKD falls disproportionately upon persons with lower socioeconomic status, who have a higher prevalence of CKD, limited access to treatment, and poorer outcomes. Therefore, identifying and treating CKD at the earliest stages is an equity imperative. In 2019, Kidney Disease: Improving Global Outcomes (KDIGO) held a controversies conference entitled "Early Identification and Intervention in CKD." Participants identified strategies for screening, risk stratification, and treatment for early CKD and the key health system and economic factors for implementing these processes. A consensus emerged that CKD screening coupled with risk stratification and treatment should be implemented immediately for high-risk persons and that this should ideally occur in primary or community care settings with tailoring to the local context.

Aerobic, resistance and combined training for adults with chronic kidney disease: A protocol for a systematic review and network meta-analysis

BACKGROUND

Chronic kidney disease (CKD) as a disease that poses a great threat to human health, which has become a public health issue of great concern. Studies have found that exercise training has a positive effect on improving the condition of chronic kidney disease. We will conduct a network meta-analysis to assess the effects of aerobic training, resistance training and combined aerobic and resistance training in treating CKD patients.

METHODS

We will search PubMed, EMBASE, Medline, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of science to identify randomized control trails (RCTs) that assessed the effect of different exercise training for CKD patients. Cochrane Handbook will be used to evaluate the risk of bias of included articles. We will use Stata or R software to perform data analysis.

RESULTS AND CONCLUSION

Our systematic review and network meta-analysis will be the first study that investigates the effect of different exercise training for CKD patients, and will provide evidence for management of chronic kidney disease.

ETHICS AND DISSEMINATION

The data involved in this study are from published articles. For this reason, there is no need for ethical approval or patient consent.

TRIAL REGISTRATION

the registration number was: CRD42020157280.

A Critical Review of Exercise Training in Hemodialysis Patients: Personalized Activity Prescriptions Are Needed

Exercise training appears to have modest or inconsistent benefits in hemodialysis patients. This may be due to the low volume and intensity of exercise often prescribed. To address this, research is needed to evaluate the efficacy of individualized exercise prescriptions as a component of a comprehensive lifestyle intervention strategy that gives patients more autonomy to choose preferred types of physical activity.

The Effect of Exercise on Nutritional Status and Body Composition in Hemodialysis: A Systematic Review

Chronic kidney disease (CKD) is associated with aggravating factors which can affect both body composition and nutritional status. The purpose of the present systematic review was to investigate the potential effects of any physical activity on body composition or nutritional status among patients with stage 5 CKD undergoing hemodialysis (HD). A literature search on PubMed, Scopus, Web of Science, Google Scholar, and Cochrane was conducted and 14 randomized clinical trials were included. Skeletal muscle index and mid-arm muscular circumference increased after resistance exercise, and the results on body mass index, % body fat, and lean body mass varied. Serum albumin and C-reactive protein, in most cases, showed a slight increase and decrease, respectively. An improvement was also observed in body strength and overall performance status. The results suggest that physical activity can be beneficial for both the body composition and nutritional status of patients undergoing HD and can help in the prevention of sarcopenia. However, further research is needed mainly in the field of nutritional status.

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.

Advances in exercise therapy in predialysis chronic kidney disease, hemodialysis, peritoneal dialysis, and kidney transplantation

PURPOSE OF REVIEW

Chronic kidney disease (CKD) is characterized by poor levels of physical activity which contribute to increased morbidity across the disease trajectory. The short nature, small samples, and poor methodology across most studies have failed to translate the role of exercise in CKD into its adoption as a frontline adjunct therapeutic option. This review focuses on recent advances surrounding the benefits of exercise interventions across the CKD spectrum.

RECENT FINDINGS

Key recent advances in exercise studies have focused on the efficacy of novel intervention strategies across the CKD spectrum. These include high-intensity interval training, virtual reality gaming, intradialytic yoga, electrical stimulation of muscles, blood flow restriction training, and protocols combining exercise with nutritional supplementation. Research is also beginning to explore the role of prehabilitation for patients prior to dialysis and kidney transplantation.

SUMMARY

Studies continue to demonstrate wide-ranging benefits of exercise across CKD; however, implementation of exercise remains scarce. Future research needs include evaluating the efficacy of larger and/or more comprehensive interventions on clinically important outcomes. It is hoped with increasing global evidence, high-quality clinical studies, and sustained clinician and patient engagement, exercise programs will become better prioritized in the nephrology field.

Safety of a Combined WB-EMS and High-Protein Diet Intervention in Sarcopenic Obese Elderly Men

Purpose

Whole-body electromyostimulation (WB-EMS) especially in combination with a high-protein supplementation has been established as an efficient treatment against sarcopenia. However, there are several case reports of rhabdomyolysis after WB-EMS application. Thus, we asked if this training could potentially lead to deteriorations of the cardiac as well as the renal function.

Materials and Methods

One hundred sarcopenic obese men aged 70 years and older were randomly balanced (1-1-1) and allocated to one of the three study arms. During 16 weeks of intervention, these groups either performed WB-EMS and took a protein supplement (WB-EMS&P), solely received the protein supplement (Protein) or served as control group (CG). WB-EMS consisted of 1.5×20 min (85 Hz, 350 μs, 4 s of strain to 4 s of rest) applied with moderate-to-high intensity while moving. We further generated a daily protein intake of 1.7-1.8 g/kg/body mass per day. At baseline and 8-10 days after completion of the intervention, blood was drawn and biomarkers of muscle, cardiac and renal health were assessed.

Results

Hereby, we found slight but significant elevations of creatine kinase (CK) levels in the WB-EMS group pointing to minor damages of the skeletal muscle (140 U/l [81-210], p < 0.001). This was accompanied by a significant, low-grade increase of creatine kinase-muscle brain (CK-MB, 0.43 ng/mL [-0.29-0.96], p < 0.01) and high-sensitivity troponin T (hsTnT, 0.001 ng/mL. [0.000-0.003], p < 0.001) but without a higher risk of developing heart failure according to N-terminal prohormone of brain natriuretic peptide (NT-proBNP, -5.7 pg/mL [-38.8-24.6], p = 0.17). Estimated glomerular filtration rate (eGFR) was impaired neither by the high-protein supplementation alone nor in combination with WB-EMS (CG 76.0 mL/min/1.73 m² [71.9-82.2] vs Protein 73.2 mL/min/1.73 m² [63.0-78.9] vs WB-EMS&P 74.6 mL/min/1.73 m² [62.8-84.1], p = 0.478).

Conclusion

In conclusion, even in the vulnerable group of sarcopenic obese seniors, the combination of WB-EMS with a high-protein intake revealed no short-term, negative impact on the eGFR, but potential consequences for the cardiovascular system need to be addressed in future studies.

Sedentary behaviour, physical activity, and renal function in older adults: isotemporal substitution modelling

Background

Physical inactivity and sedentary behaviour (too much sitting) can contribute to renal dysfunction. However, the potential benefits of behavioural change (e.g. replacing sedentary behaviour with physical activity) on renal function are not well understood. We used isotemporal substitution to model potential impacts of behaviours on renal function by replacing time spent in one behaviour to another.

Methods

In 174 older Japanese adults (age, 50–83 years; females, 76%), the time spent in sedentary behaviour, light-intensity physical activity (LPA), and moderate- to vigorous-intensity physical activity (MVPA) were assessed using an uniaxial accelerometer. Renal function was evaluated by the estimated glomerular filtration rate (eGFR) from serum creatinine and cystatin C levels.

Results

In univariate analyses, eGFR was significantly, albeit weakly, correlated with time spent in sedentary behaviour (r_s = − 0.229), LPA (r_s = 0.265), and MVPA (r_s = 0.353). In the isotemporal substitution models, replacement of 30 min/day of sedentary behaviour with an equivalent LPA time was not significantly associated with eGFR (β = 2.26, p = 0.112); however, replacement with an equivalent time of MVPA was beneficially associated with eGFR (β = 5.49, p < 0.05).

Conclusions

These cross-sectional findings suggest that sedentary behaviour (detrimentally) and physical activity (beneficially) may affect renal function and that replacing sedentary behaviour with MVPA may benefit renal health in older adults.