Rehabilitation, aging and chronic renal disease

Effect of a Home Exercise Program Based on Tai Chi in Patients with End-Stage Renal Disease

Objective

Previous reports have documented the benefits of exercise on the well-being of renal patients. However, fewer than 50% of our end-stage renal disease (ESRD) patients engage in regular exercise. To promote exercise, we implemented a home-based exercise program. The aim of the program was to reduce barriers to exercise by helping patients to exercise at their convenience and without the need to travel. The effect of the program was evaluated 3 months after implementation.

Patients and Methods

Each study participant received a videotape that demonstrated 30 minutes of low-capacity aerobic exercise. Participants were advised to exercise by following the demonstration on the videotape. Encouragement was given over the telephone. Self-reports on practice were recorded in a log book that was also provided. The effect of the program was evaluated by comparing outcomes data before, and 3 months after, implementation of the program. Outcomes assessment included functional mobility (timed “Up & Go” test), muscle flexibility (“Sit & Reach” test), physical capacity (“Six-Minute Walk”), and quality of life [Kidney Disease Quality of Life Short Form (KDQOL-SF)].

Results

The program began with 72 participants. Over time, 39 dropped out. The remaining 33 participants included 11 men and 22 women with a mean age of 52.8 ± 9.8 years. They exercised 3 – 7 times weekly. Significant improvements were observed in the timed “Up & Go” ( p = 0.003) and “Sit & Reach” ( p < 0.001) tests. Improvements in the “Six-Minute Walk” ( p = 0.130) and in KDQOL-SF scores for emotional well-being ( p = 0.456), pain ( p = 0.100), burden of kidney disease ( p = 0.061), and general health ( p = 0.085) were statistically insignificant.

Conclusions

Physically, patients with ESRD benefit from home-based low-capacity aerobic exercise. A home-based program provides an alternative to outdoor and group exercise. In view of a high drop-out rate, intensive promotion and encouragement should be considered to achieve a positive outcome.

Successful Self-Care Home Dialysis in the Elderly: A Single Center's Experience

Objective

This study was designed to prospectively review our experience with self-care home dialysis in the 60-years-and-older age group since the commencement of continuous ambulatory peritoneal dialysis (CAPD) in our center in 1989.

Design

Data on mortality, morbidity, dialysis technique and complications, quality of life, and rehabilitation were collected prospectively.

Setting

A regional dialysis unit providing full renal replacement services for a population of 292 000.

Patients

Twenty-five patients (16 male) with an average age of 64.4 years (range: 58.25-76.5 years) at commencement of dialysis.

Results

All patients were on self-care home dialysis. Patient survival rates were comparable with the national average at 12 months (90% vs 89%) and two years (84% vs 80%). Dialysis therapy was well tolerated and technique survival rates were comparable for both hemodialysis and CAPD. There was a very low peritonitis rate of 1 episode per 28.5 patient-months.

Conclusions

Self-care home dialysis is a viable therapeutic option with a high degree of technique success and a good quality of life in the older population.

Exercise training for adults with chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) is a worldwide public health problem. In the National Kidney Foundation Disease Outcomes Quality Initiative guidelines it is stressed that lifestyle issues such as physical activity should be seen as cornerstones of the therapy. The physical fitness in adults with CKD is so reduced that it impinges on ability and capacity to perform activities in everyday life and occupational tasks. An increasing number of studies have been published regarding health effects of various regular exercise programmes in adults with CKD and in renal transplant patients.

OBJECTIVES

We aimed to: 1) assess the effects of regular exercise in adults with CKD and kidney transplant patients; and 2) determine how the exercise programme should be designed (e.g. type, duration, intensity, frequency of exercise) to be able to affect physical fitness and functioning, level of physical activity, cardiovascular dimensions, nutrition, lipids, glucose metabolism, systemic inflammation, muscle morphology and morphometrics, dropout rates, compliance, adverse events and mortality.

SEARCH STRATEGY

We searched the Cochrane Renal Group's specialised register, CENTRAL, MEDLINE, EMBASE, CINAHL, Web of Science, Biosis, Pedro, Amed, AgeLine, PsycINFO and KoreaMed. We also handsearched reference lists of review articles and included studies, conference proceeding's abstracts. There were no language restrictions.Date of last search: May 2010.

SELECTION CRITERIA

We included any randomised controlled trial (RCT) enrolling adults with CKD or kidney transplant recipients undergoing any type of physical exercise intervention undertaken for eight weeks or more. Studies using less than eight weeks exercise, those only recommending an increase in physical activity, and studies in which co-interventions are not applied or given to both groups were excluded.

DATA COLLECTION AND ANALYSIS

Data extraction and assessment of study and data quality were performed independently by the two authors. Continuous outcome data are presented as standardised mean difference (SMD) or mean difference (MD) with 95% confidence intervals (CI).

MAIN RESULTS

Forty-five studies, randomising 1863 participants were included in this review. Thirty two studies presented data that could be meta-analysed. Types of exercise training included cardiovascular training, mixed cardiovascular and resistance training, resistance-only training and yoga. Some studies used supervised exercise interventions and others used unsupervised interventions. Exercise intensity was classed as 'high' or 'low', duration of individual exercise sessions ranged from 20 minutes/session to 110 minutes/session, and study duration was from two to 18 months. Seventeen per cent of studies were classed as having an overall low risk of bias, 33% as moderate, and 49% as having a high risk of bias.The results shows that regular exercise significantly improved: 1) physical fitness (aerobic capacity, 24 studies, 847 participants: SMD -0.56, 95% CI -0.70 to -0.42; walking capacity, 7 studies, 191 participants: SMD -0.36, 95% CI-0.65 to -0.06); 2) cardiovascular dimensions (resting diastolic blood pressure, 11 studies, 419 participants: MD 2.32 mm Hg, 95% CI 0.59 to 4.05; resting systolic blood pressure, 9 studies, 347 participants: MD 6.08 mm Hg, 95% CI 2.15 to 10.12; heart rate, 11 studies, 229 participants: MD 6 bpm, 95% CI 10 to 2); 3) some nutritional parameters (albumin, 3 studies, 111 participants: MD -2.28 g/L, 95% CI -4.25 to -0.32; pre-albumin, 3 studies, 111 participants: MD - 44.02 mg/L, 95% CI -71.52 to -16.53; energy intake, 4 studies, 97 participants: SMD -0.47, 95% CI -0.88 to -0.05); and 4) health-related quality of life. Results also showed how exercise should be designed in order to optimise the effect. Other outcomes had insufficient evidence.

AUTHORS' CONCLUSIONS

There is evidence for significant beneficial effects of regular exercise on physical fitness, walking capacity, cardiovascular dimensions (e.g. blood pressure and heart rate), health-related quality of life and some nutritional parameters in adults with CKD. Other outcomes had insufficient evidence due to the lack of data from RCTs. The design of the exercise intervention causes difference in effect size and should be considered when prescribing exercise with the aim of affecting a certain outcome. Future RCTs should focus more on the effects of resistance training interventions or mixed cardiovascular- and resistance training as these exercise types have not been studied as much as cardiovascular exercise.

Exercise program to enhance physical performance and quality of life of older hemodialysis patients: a feasibility study

OBJECTIVE

Evaluate the feasibility of implementing a combined in-hospital and home-based exercise program in older hemodialysis (HD) patients.

DESIGN

A prospective longitudinal 12-week pilot study.

SETTING

A university hospital HD unit and patients' homes.

PARTICIPANTS

A convenience sample of nine older (>55 years) patients undergoing HD.

INTERVENTIONS

An individualized exercise program performed on HD days (3/week) and at home (2-3/week), including aerobic, flexibility, strength exercises and patient education.

MAIN OUTCOME MEASURES

Feasibility measure: patient participation. Exercise performance: Duke Activity Status Index (DASI); 2-min walk test (2MWT); Timed-up-and-go (TUG). Quality of life: The Illness Intrusiveness Ratings Scale (IIRS); The Kidney Disease Quality of Life Questionnaire (KDQOL).

RESULTS

The mean (SD) age of the patients was 68.1 (7.1). Participation in the in-hospital supervised exercise program was high, with patients exercising during 89% of HD sessions, but was lower for the unsupervised home-based component (56% exercised ≥ 2 times/week). Patients showed a gradual increase in the amount of exercise performed over 12 weeks. The 2MWT, TUG, IIRS and the KDQOL physical composite score demonstrated moderate responsiveness, while the DASI score exhibited only limited responsiveness.

CONCLUSIONS

This exercise program and the outcome measures were feasible for older HD patients: in-hospital participation was high, and physical performance and QOL measures exhibited moderate levels of responsiveness. Future, larger studies are needed to demonstrate whether intra-dialysis exercise, with or without home exercise, can lead to improved outcomes in this population.

Perceived barriers to employment among persons living with HIV/AIDS

This study examined factors associated with contemplating returning to work among unemployed persons living with HIV/AIDS (PLHA) in a large urban city in the United States. A mailed, self-administered survey gathered information from 757 unemployed PLHA. Chi-square and logistic regression analyses were used to determine associations between contemplating returning to work and sociodemographic characteristics, health factors and perceived barriers to employment. We found that most unemployed PLHA (74%) were thinking of returning to work, but perceived significant barriers such as loss of disability income benefits (73%), loss of publicly-funded health insurance (67%) and workplace discrimination (66%). Univariate analyses indicated that contemplating returning to work was significantly associated with sociodemographic characteristics, health factors and perceived barriers to employment in the following areas: (1) availability of health insurance, (2) personal health and physical ability, (3) health concerns related to working and the work environment, and (4) current job skills. Multivariate analyses indicated that: gender, age, race/ethnicity, health insurance type, health status and the belief that health will improve if employed were independently associated with contemplating returning to work. In summary, a substantial proportion of unemployed PLHA may contemplate re-entering the workforce. Assistance is needed to help PLHA address perceived barriers that may prevent them from seeking employment.

Projecting the United States ESRD population: Issues regarding treatment of patients with ESRD

In 2001, there were 406,081 patients who received treatment for end-stage renal disease (ESRD), increasing by 4.2% since 2000. The number of patients with ESRD has grown consistently over the past decade, with the greatest rate of growth occurring among patients older than 75 years of age, and patients with comorbidities such as diabetes mellitus and hypertension. Current projections indicate that the population of patients with ESRD may reach more than 2 million by 2030. The overall mortality rate has fallen by 10% since 1988, with the greatest decline among patients incident to dialysis, and an increase among patients receiving dialysis for greater than five years. While the rate of hospitalization for ESRD patients has remained relatively constant, recent improvements in mortality are temporally associated with a greater proportion of patients achieving adequate benchmarks of care in dialytic processes, such as anemia correction and dose of dialysis. The ESRD program consumes 6.4% of the Medicare budget. On a per-patient per month basis, Medicare costs have risen between 1991 and 2001. While payments fell slightly during 1998 and 1999 because of changes in Medicare policies, more recent years have seen an upswing in total expenditures, presumably related to use of injectables not included in the composite rate. Continued growth in the number of new patients reaching ESRD, as well as improved mortality rates of ESRD patients, are both contributing to the current rise and projected epidemic of ESRD over the next 25 years. The current public health strategy of identification of patients with early kidney disease to slow their progression to ESRD, in addition to aggressive treatment strategies to minimize the morbidity and mortality of patients with ESRD, is essential toward affecting the growth and health of this population.

Disablement and rehabilitation in end-stage renal disease

Patients with end-stage renal disease (ESRD) are encumbered by disabilities in spite of advances in medical treatments. Research shows that exercise training is one way to improve physical work capacity and reduce functional limitations that impede role behaviors, such as shopping, personal care, homemaking, and yard maintenance. However, exercise training does not ameliorate some of the psychosocial and environmental factors that exacerbate disabilities for patients with ESRD. A disability process model described in this review illustrates that disability prevention may be more effective if exercise rehabilitation is integrated with self-management education. Research is needed to delineate which disabilities in patients with ESRD are a product of psychosocial factors and physical environments. Once identified, those disability risk factors that are amenable to change can guide the development of tailored rehabilitation interventions.

Inpatient rehabilitation of patients requiring hemodialysis11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVE

To evaluate the outcomes of patients who require hemodialysis and are admitted to an inpatient rehabilitation unit.

DESIGN

Retrospective review of the data of all admissions to an inpatient rehabilitation unit in 2001.

SETTING

University medical center.

PARTICIPANTS

All inpatient rehabilitation admissions in 2001 (N=531), including 497 patients who did not require hemodialysis and 34 who required hemodialysis.

INTERVENTION

A comprehensive rehabilitation program including physical therapy and occupational therapy. Speech and language therapy and rehabilitation psychology were provided when necessary.

MAIN OUTCOME MEASURES

Length of stay (LOS), change in total score on the FIM instrument, FIM efficiency, and place of discharge.

RESULTS

Admission and discharge FIM scores of the patients requiring hemodialysis were virtually identical to those of the other patients admitted to the unit. The average LOS of the hemodialysis patients was 5.4 days longer than that of the other patients, and, therefore, efficiency scores of the dialysis group were less than those of the other patients. The rate of discharge to the community did not differ significantly for the dialysis group.

CONCLUSIONS

Patients who require hemodialysis can benefit from rehabilitation services. Their improvement on the FIM instrument is comparable to that of other patients, but their LOS may be longer than that of other patients.

Perceived employment barriers and their relation to workforce-entry intent among people with HIV/AIDS

As treatments have improved health and quality of life for people with HIV/AIDS, many have contemplated workforce reentry. Workforce reentry rarely occurs among people with illness-related disability. The authors mailed a survey that included workforce-entry-related concerns to 1,991 HIV/AIDS clients. Factor analysis extracted 6 areas of concern (benefits loss, work-related health, job skills, discrimination, personal health care, workplace accommodation). Levels of concern generally increased with HIV acuity level and time since last worked. Work-related health concerns predicted consideration of workforce entry, and work-related health concerns and benefits-loss concerns predicted estimated time to return to work. Findings provide quantitative validation of intuitive categories of workforce-entry concerns among people with HIV/AIDS and suggest that concerns may shift with progress toward workforce entry.

Exercise for the dialyzed: aerobic and strength training during hemodialysis

OBJECTIVE

To investigate the safety and feasibility of aerobic and strength training during hemodialysis for end-stage renal disease patients and to evaluate its impact on their cardiac fitness, muscle strength, and functional status.

DESIGN

A total of 22 patients undergoing hemodialysis for end-stage renal disease had assessment of their cardiac fitness with stress tests and walk tests, assessment of their muscle strength by one repetition maximum of knee extension, and assessment of their functional status by Medical Outcomes Study Short Form-36 before and after exercise training. Training, consisting of cycle ergometer exercise and strengthening of the knee extensors two to three times a week for 3 mo, was done during dialysis.

RESULTS

Eighteen of 22 patients completed 3 mo of training and four dropped out due to knee pain or medical complications unrelated to exercise. No patient developed major complications from the program. After training, there was a significant improvement in the mental and physical components of the Short Form-36 and one repetition maximum of knee extension. Among 14 of 18 patients who agreed and completed a follow-up fitness testing, five showed improvement on the stress tests and eight on the walk tests.

CONCLUSIONS

A well designed exercise program during hemodialysis can be performed safely with proper supervision and patient education, improving muscle strength, mental and physical function, and possibly cardiac fitness.

Ambulatory blood pressure monitoring in chronic renal disease: technical aspects and clinical relevance

PURPOSE OF REVIEW

To evaluate the current value of ambulatory blood pressure monitoring in patients with chronic renal disease and end-stage renal disease.

RECENT FINDINGS

Ambulatory blood pressure monitoring has become an important tool in hypertension research and clinical practice. Its use in essential hypertension shows a strong predictive ability in the assessment of cardiovascular outcomes. In chronic renal failure and end-stage renal disease, the role of ambulatory blood pressure monitoring is still being actively evaluated, and available evidence shows that it is better than office blood pressure in predicting left ventricular hypertrophy and progression of renal dysfunction in patients with chronic renal failure. In end-stage renal disease, preliminary data suggest better prediction of mortality in hemodialysis patients in comparison with clinic blood pressures. The most conspicuous problems with the literature on this subject are small sample sizes and the paucity of longitudinal observational studies and intervention trials.

SUMMARY

Preliminary data and extrapolations from essential hypertension have justified a growing excitement about the use of ambulatory blood pressure monitoring in renal disease. However, further research will have to address the limitations of the available literature before generalization of its use is implemented.

Psychosocial predictors of non-compliance in haemodialysis and peritoneal dialysis patients

BACKGROUND

Non-compliance with prescribed therapy significantly impacts dialysis patient care and outcomes. The underlying psychosocial issues leading to non-compliance are not well understood, especially in peritoneal dialysis (PD) patients.

METHODS

A multicentre cohort of 119 haemodialysis (HD) patients and 51 PD patients was studied. In-person interviews were conducted with patients and clinical and laboratory data were obtained from medical records. Missed and shortened dialysis treatments/sessions and excessive serum phosphate values provided indicators of non-compliance. Patients' perceived health status, perceived self-health care, depression, perceived control over future health, social support, and disease-specific perceived quality of life were measured, along with current smoking status. Associations of predictor variables with non-compliance indicators were examined in univariate and multivariable analyses.

RESULTS

Approximately one-third of both HD and PD patients were non-compliant on at least one indicator. Logistic regression models identified a significant association between smoking and each non-compliance indicator. Patient age (younger) also predicted missed treatments. Perceived (negative) effects of kidney disease on daily life, and (decreased) perceived control over future health also predicted shortened treatments. No significant association was found between dialysis modality (HD vs PD) and non-compliance.

CONCLUSION

Smoking, one marker of priority placed on health status, and intrusiveness/control issues should be addressed in intervention efforts to improve compliance in patients treated by HD and PD.

Differential survival after coronary revascularization procedures among patients with renal insufficiency

BACKGROUND

Acute myocardial infarction, cardiac arrest, and other cardiac events are the major cause of mortality among patients with renal insufficiency. Previous studies of interventions for coronary artery disease among patients with renal insufficiency have not controlled for potentially confounding factors such as coronary artery disease severity and left ventricular function. This study investigates the comparative survival for patients with renal insufficiency and coronary artery disease following coronary artery bypass graft (CABG) surgery as compared with percutaneous coronary artery intervention (PCI), while controlling for confounding factors.

METHODS

This retrospective cohort study of patients undergoing CABG surgery or PCI discharged between 1993 and 1995 uses the New York Department of Health databases and Cox proportional hazards analyses to estimate the mortality risk associated with CABG as compared with PCI for patients with renal insufficiency. Renal function was categorized as creatinine <2.5 mg/dL (N = 58,329), creatinine > or =2.5 mg/dL (N = 840), and end-stage renal disease (ESRD) requiring dialysis (N = 407).

RESULTS

Patients with either ESRD or serum creatinine > or =2.5 mg/dL had more severe coronary artery disease and a greater frequency of comorbid conditions as compared with patients with creatinine <2.5 mg/dL. Creatinine > or =2.5 mg/dL and ESRD were both associated with an increased mortality risk among all distributions of coronary artery disease anatomy. Among patients with ESRD, the risk ratio (RR) of mortality for patients undergoing CABG compared with PCI was 0.39 (95% CI, 0.22 to 0.67, P = 0.0006). Among patients with creatinine > or =2.5 mg/dL, CABG surgery did not convey a survival benefit over PCI (RR, 0.86, 95% CI, 0.56 to 1.33, P = 0.50).

CONCLUSIONS

This study demonstrates a survival benefit among patients with ESRD undergoing CABG surgery as compared with PCI, while controlling for severity of coronary artery disease, left ventricular dysfunction, and other comorbid conditions. These results suggest that management decisions among patients with coronary artery disease should be made in the context of not only location and severity of coronary artery lesions, but also on the presence and severity of renal dysfunction.

The life readiness program: a physical rehabilitation program for patients on hemodialysis

Patients with end-stage renal disease (ESRD) undergoing hemodialysis (HD) are typically sedentary and functionally limited as a consequence of their condition. The purpose of this study is to test the effect of a lifestyle physical rehabilitation program (The Life Readiness Program) on physical function in patients with ESRD undergoing HD. Physical function was measured by the Kidney Disease Quality of Life Short Form (KDQOL-SF) physical function score (range, 0 to 100). Eighty-two patients were randomly assigned to a 6-month rehabilitation program (intervention; n = 39) or to standard clinical management alone (control; n = 43). The groups were frequency matched by age, sex, ethnicity, and diabetes as the cause of ESRD. General linear modeling of the change in physical function score was used for multivariate analysis. Physical function scores were not different between groups at baseline. Change in physical function score increased significantly in the intervention group compared with the control group when data were adjusted for the matching variables and adequacy of dialysis (3.2, -3.6; P = 0.04). Additionally, the control group reported more problems with work or daily functions because of emotional problems (P: </= 0.05). In this brief 6-month intervention, The Life Readiness Program showed the therapeutic benefit of a lifestyle rehabilitation program on functional outcomes and health-related quality of life for patients with ESRD undergoing hemodialysis.

Psychosocial factors in adult end-stage renal disease patients treated with hemodialysis: correlates and outcomes

The first three decades of the ESRD program were devoted to extending patient survival. Few data have been generated regarding the factors associated with successful patient adjustment. Depression and perception of the effects of illness are important responses to the experience of ESRD and may be associated with differential survival. Perception and extent of social support can moderate these factors. The association of psychosocial factors and assessments of quality of life are incompletely understood and are topics of research interest. The role of variation in socioeconomic status in association with these factors has not been extensively studied. The challenges for the next 30 years include understanding the relationship of psychosocial factors to demographic and medical factors in large ESRD patient populations and the refinement of associations between psychosocial factors and patient outcomes, including adjustment, compliance, morbidity, and mortality.

Self-reported functional status: an important predictor of health outcomes among end-stage renal disease patients

A contemporary focus on outcomes assessment has provided affirmation that patient functional status is both an important outcome of medical care and an important predictor of longer term outcomes such as morbidity and/or mortality. Monitoring functional status among end-stage renal disease (ESRD) patients is particularly critical because the cycle of physical deconditioning experienced by renal patients is both insidious and malignant. Over the past several years, patient self-report instruments have been used with increasing frequency to assess functioning. Among ESRD patients, such self-reports have reliably predicted mortality and some morbidity. Additionally, renal patients' self-reported functioning is also correlated with the results of several commonly performed laboratory tests. Based on these findings, measures of self-reported functional status might be considered a practical adjunct to regular patient assessments. They could be routinely used for purposes that might include: identifying the particular areas of functioning and well-being that need improvement; screening for subtle changes in health status; establishing physical status baselines; and corroborating the effectiveness of physical activity interventions. Overall, ESRD patients' self-report of their functioning appears to secure, synthesize, and standardize data about patient health status that is unavailable through any other mechanism. Such information may be essential to medicine's primary missions of promoting health and preserving life.

Wellness self-care by healthy older adults

PURPOSE

To examine self-care behaviors in healthy older adults. The number of older adults continues to increase. Nurses need a framework for understanding and supporting healthy behaviors in this population.

DESIGN

Descriptive.

METHOD

Data about self-care behaviors were elicited in 1997 about how healthy older adults stay well. Using a key-informant criterion and critical case approach, a small convenience sample of 28 older adults (ages 57-83) responded to a questionnaire based on a self-care wellness model.

FINDINGS

Age was not related to differences in healthy behaviors. Many informants reported no digestive or sleep difficulties. All were active, regularly kept in touch with family and friends, were confident their environment was safe, obtained sufficient sleep and rest, and managed stress well. All but one attributed their quality of life and zest for living to remaining active, eating healthy food, exercising, pacing themselves, doing preferred activities, and reading the Bible, or "feeding the life of the mind."

CONCLUSIONS

Participant statements of actions can provide inspiration for less-active seniors and a beginning framework for nurses for understanding and supporting wellness self-care behaviors in older adults.

Exercise training by individuals with predialysis renal failure: cardiorespiratory endurance, hypertension, and renal function

The purpose of this study was to determine the effects of 4 months of exercise training (ET) on cardiorespiratory function and endurance, blood pressure, muscle strength, hematology, blood lipids, and renal function in individuals with chronic renal failure (CRF) who were not yet on dialysis. Sixteen subjects were recruited to volunteer for participation in this study, but only eight completed all study phases. Subjects were first evaluated before and after a 2-month baseline (BL1 and BL2), after 4 months of ET, and again after 2 months of detraining (DT). ET did not change hematology, blood lipids, or echocardiographic measurements of left ventricular function and mass. Resting systolic and diastolic blood pressures decreased significantly from BL after the ET (146 +/- 15.7/87 +/- 9 mm Hg to 124 +/- 17.5/78 +/- 9.5 mm Hg; P < 0.02), and then increased significantly after DT (139 +/- 14.7 mm Hg and 87 +/- 9.9 mm Hg; P < 0.01). Peak oxygen consumption (pVO2) changed significantly during the study (1.3 +/- 0.3 L/min, 1.5 +/- 0.3 L/min, and 1.4 +/- 0.3 L/min for BL2, ET, and DT, respectively; P < 0.02), as did the VO2 at the ventilatory threshold (0.65 +/- 0.18 L/min, 0.92 +/- 0.19 L/min, and 0.68 +/- 0.23 L/min for BL2, ET, and DT, respectively; P < 0.01). Knee flexion peak torque increased after ET (43.4 +/- 25.6 Nm to 51.0 +/- 30.5 Nm; P < 0.02). GFR, as measured by creatinine clearance, continued to deteriorate during the course of the study (25.3 +/- 12.0 mL/min, 21.8 +/- 13.2 mL/min, and 21.8 +/- 13.2 mL/min for BL2, ET, and DT, respectively; P < 0.001). Individuals with predialysis CRF who undergo ET improve in functional aerobic capacity, muscular strength, and blood pressure.

Differences between employed and nonemployed dialysis patients

Three hundred fifty-nine chronic dialysis patients (85 employed and 274 nonemployed) were surveyed to identify/verify those characteristics which differentiate between employed versus nonemployed status. Education emerged as a significant correlate of employment, as noted by previous investigators, whereas, unlike previous research, neither mode of dialysis, length of time on dialysis, number of comorbid conditions, nor cause of renal failure (eg, diabetes) were associated with employment status. Measures of functional status (MOS SF-20 and Karnofsky) were positively associated with employment. Furthermore, patients' perceptions that their health limited the type and amount of work that they could do were negatively associated with employment. In addition, using a series of de novo items, we found subjects' beliefs about dialysis patients' ability to work to be a "self-fulfilling prophecy" with regard to employment status. That is, patients who themselves believed that dialysis patients should work and had this notion reinforced by significant others were more likely to be employed. Interestingly, 21 percent of unemployed patients reported that they were both able to work and wanted to return to work. Because it is consistently reported that only a small percentage of dialysis patients are employed, targeting the patients who are both willing and able to work for vocational rehabilitation might significantly increase the numbers of employed dialysis patients.

Deficits in lower extremity muscle and gait performance among renal transplant candidates

This study was performed to determine the reliability and convergent validity of two lower extremity muscle performance (LEMP) measurements and to describe deficits in and determinants of LEMP and gait performance. Cross-sectional case series and criterion standard designs were used. The study took place at a tertiary care center. The subjects were referred from a volunteer sample of 110 renal transplant candidates. There were no interventions. The main outcome measures were knee extension strength measured by hand-held dynamometry and a sit-to-stand-to-sit (STSTS) test; gait independence on level surfaces and stairs; comfortable and maximum gait speed. Dynamometer measurements were reliable within (intraclass correlation coefficient (ICC) > or = .976) and between (ICC > or = .953) testers. Repeated STSTS measurements were also reliable (ICC > or = .843). The LEMP measures correlated significantly (p < .001) with one another (r > or = .406, R > or = .445). Compared with values predicted by regression equations derived from healthy individuals, transplant candidates showed significant deficits in knee extension force (33.2% to 34.6%) and gait speed (20.5% to 22.7%). Consistent as determinants of LEMP were sex, weight, and diabetic status. STSTS performance was the most consistent determinant of gait performance. The results of this study support the use of the STSTS test to characterize LEMP in kidney transplant candidates, particularly those who are diabetic or have deficits in gait performance.

Functional outcomes after inpatient rehabilitation of patients with end-stage renal disease

There is a paucity of information on functional benefits of inpatient rehabilitation of patients with end-stage renal disease (ESRD). This study examined admission and discharge Functional Independence Measure (FIM) scores of 45 ESRD patients admitted over a 33-month span to determine if these patients made functional gains similar to 2,324 concurrently admitted general rehabilitation patients without ESRD. FIM scores were transformed and reported as scaled (0 to 100) motor and cognitive subscores by the Rasch method. FIM scores were compared using multiple linear regression to control for differences in rehabilitation diagnosis and other confounding factors between the ESRD and other patients. ESRD subgroups were compared using one-way analysis of variance. The mean discharge motor FIM score unadjusted for confounders was lower in ESRD than general rehabilitation patients (45.18 vs 50.63), and the difference after regression analysis (7.63 points lower in the ESRD group) was significant (p < .01). The mean motor FIM score gain after regression analysis for the two groups showed only a near significant (p = .06) difference, with the gain among ESRD patients being 3.15 points lower. Discharge settings were similar, with 89% of ESRD patients and 87% of patients without ESRD being discharged home. ESRD patients on hemodialysis had similar FIM scores to patients with renal transplantation. ESRD patients with stroke had significantly lower (p < .05) discharge motor and cognitive scores than ESRD patients with generalized weakness or amputation. In addition, stroke patients with ESRD showed significantly lower motor FIM score gains than stroke patients without ESRD (5.09 vs 11.08; p = .002).(ABSTRACT TRUNCATED AT 250 WORDS)

Muscle strength impairments and gait performance deficits in kidney transplantation candidates

The purposes of this study of patients referred for renal transplant were to describe muscle strength impairments and deficits in gait performance and to establish the relationship between them. Twenty-six patients were tested. Muscle strength measurements included grip, elbow flexion, and shoulder abduction in the upper extremities, and ankle dorsiflexion, knee extension, hip abduction, and timed sit-to-stands in the lower extremities. Gait performance (level ground and stair) was quantified using ordinal scales and speed. Compared with healthy control subjects, patients demonstrated impairments in muscle strength and deficits in gait performance. Patients with diabetes demonstrated greater impairments and deficits than patients without diabetes. Patients with an active fistula demonstrated better grip strength in their upper extremity without the fistula. Gait performance was correlated significantly with lower extremity strength, with knee extension strength and weight providing the best prediction of gait speed (R2 = 0.478 to 0.617). The results of this study suggest that patients referred for renal transplantation possess both strength impairments and deficits in gait performance, the latter being related to the former. The clinician wishing to efficiently monitor strength impairments among patients referred for transplantation can obtain a reasonable indication of them from dynamometric grip and knee extension strength measurements.