Association between physical activity and change in renal function in patients after acute myocardial infarction

Impact of online support of physical activity management using a wearable device on renal function in patients with acute coronary syndrome: a randomized controlled trial protocol

Background

Acute coronary syndromes (ACS) often cause rapid decline in renal and cardiac function. In patients with ACS, combined renal dysfunction is associated with increased overall mortality and cardiovascular events. Physical activity (PA) management may crucially contribute towards protection of renal function in patients with ACS. This article describes the study protocol of a randomized controlled trial (RCT) assessing whether online support for PA management using wearable devices and information communication technology for patients with ACS facing difficulties in participating in outpatient cardiac rehabilitation after discharge can protect renal function following disease onset.

Methods

We have designed a two-arm RCT with a 3-month follow-up period. The online support intervention incorporates monitoring of PA, pulse rate, and blood pressure using a wearable device with an accelerometer and a web application system, as well as periodic educational feedback and goal setting. The primary study endpoint is the estimated glomerular filtration rate based on serum cystatin C (eGFRcys). The intervention effect will be assessed using the eGFRcys at 3 months adjusted for baseline values. The secondary endpoints are the urine albumin/creatinine ratio, brain natriuretic peptide levels, average step count, peak oxygen uptake, quality of life, and incidence of adverse events.

Discussion

This RCT will provide evidence regarding the effectiveness of online support for PA management as a renal protection strategy following ACS onset. This novel strategy not only mitigates barriers impeding participation in outpatient cardiac rehabilitation and protects cardiac and renal function in patients with ACS, but also may contribute towards improving survival and recurrence rates, preventing dialysis, and reducing medical and long-term care costs.

Trial registration

The trial was registered in the Japan Registry of Clinical Trials on July 5, 2024. The registration number is jRCT1022240014 (Impact of Online Support of Physical Activity Management Using a Wearable Device on Renal Function in Patients with Acute Coronary Syndrome).

Multimorbidity and Multiple Disabilities: Present Status and the Roles of Rehabilitation

The world is aging, and an increasing number of countries are becoming aged or super-aged societies. Japan has already become the world's first super-aged society, with an aging rate of 29.1% of the entire population of the country. As of 15 September 2021, there were approximately 36.40 million people aged 65 years and over. The advent of the super-aged society has increased the possibility of multimorbidity and multiple disabilities (MMDs) in the elderly population. According to a survey by the Ministry of Health, Labour and Welfare, the percentage of people with multiple disabilities of all people with physical disabilities has fluctuated between 4.0 and 7.0%, but rapidly increased to 8.9% in 2006 and 17.7% in 2016. This review aimed to establish the present status of MMDs and the rehabilitation for MMDs. In rehabilitation settings, patients with MMDs are more common than patients with a single disease or disability; however, evidence on MMD rehabilitation is insufficient. Inexperienced and unconfident medical professionals are overly cautious in providing rehabilitation; therefore, adequate rehabilitation is not provided. Furthermore, to respond to the rehabilitation needs of patients with MMDs, human resources need to be cultivated, and a scientific basis needs to be built. It is expected that MMD guidelines will soon be developed based on various case studies and surveys. In MMD rehabilitation, it is important to provide "wider, earlier, more intimate, and more connected rehabilitation"; for this, the training and cooperation of rehabilitation medical professionals is necessary.

Can Functional Motor Capacity Influence Mortality in Advanced Chronic Kidney Disease Patients?

Alterations in the body's nutritional status or composition may be observed as the kidney disease advances, which could influence the kidney's functional capacity and, consequently, could increase the risk of mortality. The aim of the study is to determine the influence of functional capacity on mortality assessed by different functional tests in patients with advanced chronic kidney disease (ACKD). A prospective observational study was designed, which included 225 patients followed for 8 years in a CKD clinic. The study assessed functional capacity by using a range of tests, which included the Short Physical Performance Battery, the 6 minutes walking gait test, the timed up and go, and the four versions of the sit-to-stand test. Additionally, body composition and nutritional conditions were considered, taking into consideration various biochemical indicators such as albumin, prealbumin, c-reactive protein (CRP), lymphocytes, and transferrin, muscle strength, comorbidity, and frailty. The relationship between functionality and all-cause mortality was investigated using a Cox proportional hazard model. A total of fifty patients died during the duration of the study. Patients who performed worse on the function and muscle strength tests showed a worse body composition and nutritional status, and exhibited a reduced life expectancy. Inflammation (CRP) was associated with an increased risk of mortality (model 1: hazard ratio (HR) = 1.246; 95% confidence interval (95% CI = 1.014-1.531; model 2: HR = 1.333; 95% CI = 1.104-1.610). Good functional capacity as determined by the SPPB test decreased the risk of mortality (model 1: HR = 0.764; 95% CI = 0.683-0.855; model 2 HR = 0.778; 95% CI = 0.695-0.872). Cut-off points of maximum sensitivity and specificity for mortality were obtained with different tests. The study demonstrated that functional capacity influences mortality in patients with ACKD, being higher in those patients with impaired functionality regardless of the test used, although the SPPB allows a larger number of patients to be assessed. Therefore, it is essential to incorporate the assessment of functionality into the comprehensive care of patients with CKD.

Impact of moderate to vigorous intensity physical activity on change in renal function in patients after acute myocardial infarction

Acute myocardial infarction (AMI) is associated with a decline in renal function. This study aimed to investigate the impact of engaging in moderate to vigorous intensity physical activity (MVPA) for more than 30 min per day on changes in renal function during the first 3 months after AMI onset. A prospective, observational study was conducted, enrolling 87 patients (75 men; average age, 65.2 ± 12.5 years) who had experienced AMI. The cystatin C-based estimated glomerular filtration rate (eGFRcys) was collected at and 3 months after discharge. Daily MVPA was measured using triaxial accelerometers at a threshold of 3.0 Metabolic equivalent of the task for 3 months. Generalized estimating equations (GEE) were applied to evaluate the longitudinal association between the number of days per week of MVPA for 30 min or more and within-patient changes in eGFRcys. The patients were categorized into three groups based on their MVPA engagement days: 0 days (n = 20), 1-2 days (n = 14), and 3-7 days (n = 53) groups. After adjusting for potential confounding variables, GEE analysis revealed that the eGFRcys slope over 3 months was significantly higher in the 3-7 days group than in 0 days group (B = 2.9, (95% confidence interval: 1.5-4.2), p < 0.001). Similar results were obtained when MVPA time thresholds were set to 40 and 60 min. These findings suggest a significant positive effect of engaging in MVPA for 30 min or more for 3-7 days per week in the improvement of renal function after AMI onset.

Renal Rehabilitation: Present and Future Perspectives

Chronic kidney disease (CKD) is a global health problem. In patients with CKD, exercise endurance is decreased, especially as renal dysfunction advances. This is due to the combined effects of protein-energy wasting, uremic acidosis, and inflammatory cachexia, which lead to sarcopenia and are aggravated by a sedentary lifestyle, resulting in a progressive downward spiral of deconditioning. Renal rehabilitation (RR) is a coordinated, multifaceted intervention designed to optimize a patient's physical, psychological, and social functioning, as well as to stabilize, slow, or even reverse the progression of renal deterioration, improving exercise tolerance and preventing the onset and worsening of heart failure, thereby reducing morbidity and mortality. This review focused on the history and benefits of RR in patients with CKD. Based on current evidence, RR is an effective, feasible, and safe secondary prevention strategy in CKD. RR is a promising model for a new field of rehabilitation. Therefore, efforts to increase RR implementation rates are urgently needed.

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.

Peak exercise oxygen uptake and changes in renal function in patients after acute myocardial infarction

BACKGROUND

The impact of exercise tolerance on renal function change after acute myocardial infarction (AMI) is not clear.

OBJECTIVES

The present study aimed to elucidate the effect of peak exercise oxygen uptake (VO₂) levels on longitudinal changes in renal function up to 1 year after onset of AMI.

METHODS

This retrospective longitudinal study enrolled 198 AMI patients. Symptom-limited cardiopulmonary exercise testing was performed at completion of early Phase II cardiac rehabilitation, and peak VO₂ levels were defined as the primary exposure factor. The estimated glomerular filtration rates (eGFRs) at baseline, 3 months, 6 months and 1 year were collected. Generalized estimating equation (GEE) models were used to test the longitudinal effect of peak VO₂ levels on within-patient changes in eGFR.

RESULTS

Patients were stratified into tertile groups (Low group, 12.3 ± 1.3 mL/kg/min; Mid group, 15.3 ± 0.7 mL/kg/min; and High group, 19.1 ± 2.3 mL/kg/min) according to peak VO₂ levels. The slopes of eGFR over 1 year in the Low (p = 0.024) and Mid groups (p = 0.037) were lower compared to the High group. The Low group had a significantly higher odds ratio of experiencing rapid renal function decline than the High group (odds ratio, 2.87; p = 0.012).

CONCLUSIONS

There was a significant effect of lower peak VO₂ on rapid decline in renal function after AMI. Our findings suggest that the coexistence of exercise intolerance may be a novel risk factor for rapid decline in renal function after AMI.

Onset of the COVID-19 pandemic reduced active time in patients with implanted cardiac devices

BACKGROUND

Physical inactivity and sedentary behavior are modifiable risk factors for chronic disease and all-cause mortality that may have been negatively impacted by the COVID-19 shutdowns.

METHODS

Accelerometry data was retrospectively collected from 332 permanent pacemaker (PPM) and 244 implantable cardiac defibrillation (ICD) patients for 6 time points: March 15-May 15, 2020 (pandemic period), January 1-March 14, 2020, October 1-December 31, 2019, March 15-May 15, 2019, January 1-March 14, 2019, and October 1-December 31, 2018. Paired t-tests, with Bonferroni correction, were used to compare time periods.

RESULTS

Activity significantly decreased during the pandemic period compared to one year prior by an average of 0.53 ± 1.18h/day (P < 0.001) for PPM patients and 0.51 ± 1.2h/day (P < 0.001) for ICD patients. Stratification of subjects by active time (< 2 versus ≥ 2h/day) showed patients with < 2h, particularly those with ICDs, had modestly greater activity reductions with the pandemic onset. Logistical regression analyses suggest a trend toward a greater reduction in active time at the onset of the pandemic and an increased risk of hospital or emergency department (ED) admission for PPM patients, but not ICD patients.

CONCLUSION

The onset of the pandemic in the United States was associated with a significant drop in PPM and ICD patient active hours that was modestly more pronounced in less active patients and cannot be explained by one year of aging or seasonal variation. If sustained, these populations may experience excess cardiovascular morbidity.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Association between Health-Enhancing Physical Activity and Quality of Life in Patients with Chronic Kidney Disease: Propensity Score Matching Analysis

We investigate the association between health-enhancing physical activity and the quality of life in patients with non-dialysis chronic kidney disease. We performed data analysis on 1618 of 2238 patients from 2011 to 2016, obtained from the KoreaN Cohort Study for Outcome in Patients with Chronic Kidney Disease (KNOW-CKD). Health-related quality of life was measured using the Korean version 1.3 of Kidney Disease Quality of Life short-form questionnaire. Health-enhancing physical activity was defined as 150 min of moderate-intensity or 75 min of vigorous-intensity aerobic physical activity throughout the week. Propensity score matching analysis and linear regression was performed to estimate the effect of health-enhancing physical activity on health-related quality of life. The estimate of average treatment effects was 2.60 in the kidney component summary score, 4.45 in the physical component summary score, and 4.24 in the mental component summary score. In all component summary scores and most of their subscales, health-enhancing physical activity showed a significant association with health-related quality of life. Subgroup and sensitivity analyses also showed robust results. This study suggests that health-enhancing physical activity elevated quality of life in patients with non-dialysis chronic kidney disease. The results can contribute to encourage physical activity in patients with chronic kidney disease.

Outpatient Cardiac Rehabilitation Suppresses Deterioration of Renal Function in Patients ≥75 Years of Age With Heart Disease

BACKGROUND

This study investigated the effect of outpatient cardiac rehabilitation (OCR) and physical activity on the estimated glomerular filtration rate based on serum cystatin C (eGFRcys) in patients with heart disease (HD) aged ≥75 years.

METHODS AND RESULTS

This non-randomized prospective intervention study involved 136 patients (non-OCR group, n=66; OCR group, n=70), 55 of whom were aged ≥75 years (non-OCR group, n=29; OCR group, n=26). Renal function (eGFRcys) was evaluated at discharge and 3 months thereafter. A linear mixed model (LMM) was used to assess changes in renal function over time. The hospital readmission rate within 3 months after discharge was also evaluated. LMM analysis showed that the change in eGFRcys was -2.27 and +0.48 mL/min/1.73 m2in the non-OCR and OCR groups, respectively (F=2.960, P=0.022). Further, among patients aged ≥75 years in the non-OCR and OCR groups, the change in eGFRcys was -3.83 and -1.08 mL/min/1.73 m2, respectively (F=2.719, P=0.039). The proportion of patients aged ≥75 years who were rehospitalized due to exacerbation of HD was 16.9% (n=10) and 6.7% (n=2) in the non-OCR and OCR groups, respectively.

CONCLUSIONS

Among patients with HD aged ≥75 years, participation in OCR reduces the decline in renal function and hospital readmission rates.

Association between physical activity and changes in renal function in patients after acute myocardial infarction: A dual-center prospective study

BACKGROUND

Acute myocardial infarction (AMI) causes a decline in renal function. This study aimed to elucidate the longitudinal association between physical activity levels and changes in renal function up to 6 months after the onset of AMI.

METHODS

In this dual-center prospective observational study, 73 AMI patients (67 men; average age, 65.0±11.7 years) were enrolled from 2017 to 2019. Blood biochemistry, urinalysis, and physical function tests were conducted at discharge and 3 and 6 months post-discharge. The renal function was evaluated based on cystatin C-based estimated glomerular filtration rate (eGFRcys). The number of steps was recorded for 6 months post-discharge. Generalized estimating equation (GEE) models were used to test the longitudinal association between physical activity levels and within-patient changes in eGFRcys. Both GEE models with a follow-up period of 3 and 6 months were constructed to assess the effects of the passage of time.

RESULTS

Patients were stratified into the low (n=36; 2903±1187 steps/day) and high groups (n=37; 7988±3192 steps/day) based on the median number of steps. Both GEE models at the 3- (p=0.027) and 6-month follow-up (p=0.034) showed a significant positive association between the physical activity levels and within-patient changes in eGFRcys. The changes in eGFRcys at 6 months were -0.3 mL/min/1.73 m² and +4.4 mL/min/1.73 m² among the low and high group participants, respectively.

CONCLUSIONS

There was a significant positive association between physical activity and renal function changes after the onset of AMI, which persisted when the follow-up period was extended from 3 to 6 months. Our findings support the importance of interventions that enable maintaining high physical activity levels as a strategy for preserving renal function in AMI patients.

Resistance exercise training ameliorates chronic kidney disease outcomes in a 5/6 nephrectomy model

Chronic kidney disease (CKD) is defined by decreased glomerular filtration rate (GFR) or increased albumin excretion leading to renal injury. However, exercise training is an important non-pharmacological intervention that ameliorates and protects against Diabetes Mellitus, cardiovascular disease, and CKD.

AIM

Our aim was to evaluate the capability of resistance exercise training (RET) to improve CKD outcomes and the contribution of the renal and muscular Akt/mTOR signaling pathway for RET beneficial effects on a CKD model.

MAIN METHODS

Male Wistar rats were subjected to RET, followed for 10 weeks, and randomly divided into 5 groups: Sham: Sham-operated; sedentary and nephrectomy (5/6Nx) (SNS); exercising post-5/6Nx (SNE); exercising pre-5/6Nx (ENS); exercising pre- and post-5/6Nx (ENE). The systolic blood pressure (BP) was measured. Creatinine, proteinuria, and blood urea nitrogen (BUN) were evaluated. After euthanasia Renal and muscular Akt/mTOR signaling pathways were analyzed.

KEY FINDING

Our study showed that the SNS presented renal injury, hypertension, weight and muscular mass loss and a higher mortality rate. SNS group also decreased renal IL-10 and increased TNF-alfa and TGF-Beta. Renal AKT, mTOR, and rpS6 pathway were increased, PTEN was decreased on SNS. And muscular Akt and mTOR were decreased on SNS.

SIGNIFICANCE

The RET before and after the 5/6Nx ameliorates all these parameters mentioned above, suggesting that RET is a good non-pharmacological approach to diminish complications frequently found in CKD. We also suggest that the AKT-m-TOR pathway can play an important role in these beneficial outcomes of RET on the CKD animal model.

Clinical efficacy and safety of percutaneous coronary intervention for acute myocardial infarction complicated with chronic renal insufficiency: A protocol of systematic review and meta-analysis

BACKGROUND

The aim of this research is to further evaluate the efficacy and safety of percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI) complicated with chronic renal insufficiency (CRI) by meta-analysis, to provide scientific and effective medical evidence for PCI in patients with AMI complicated with CRI, and to support the clinical application of PCI.

METHODS

Electronic databases will be searched, including PubMed, Cochrane Library, Embase, CNKI, CBM, VIP, and Wanfang Data. Patients with AMI complicated by renal insufficiency treated with PCI will be included. The retrieval time is from inception to January 2019. The inclusion and exclusion criteria are formulated to search only the relevant literature. Endnote software management for literature will be adopted. The literature will be independently screened by 2 researchers. Excel 2016 will be applied to extract literature data with the "Research Information Registration Form." The final selected literature will be assessed for bias risk. Stata 12.0 software will be used for the meta-analysis.

RESULTS

The systematic evaluation and meta-analysis will be carried out strictly in accordance with the requirements of the Cochrane System Evaluator Manual 5.3 on meta-analyses, which will provide a high-quality evaluation of the clinical efficacy and safety of PCI in patients with AMI and CRI.

ETHICS AND DISSEMINATION

This study belongs to the category of systematic reviews, not clinical trials. Therefore, it does not require ethical approval. The results of this study will be published in influential international academic journals related to this topic.

CONCLUSION

PCI is an effective and safe treatment for patients with AMI and CRI. This study will provide a definite evidence-based medical conclusion and provide a scientific basis for the clinical treatment of patients with AMI and CRI.

PROSPERO REGISTRATION NUMBER

CRD42019131367.