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Background: Understanding the patient perspective of frailty is critical to offering holistic patient-centred care. Rehabilitation strategies for patients with advanced chronic kidney disease (CKD) and frailty are limited in their ability to overcome patient-perceived barriers to participation, resulting in high rates of drop-out and non-adherence. The aim of this study was to explore patient perspectives and preferences regarding experiences with rehabilitation to inform a CKD/Frailty rehabilitation model., Methods: This qualitative study involved two focus groups, six individual semi-structured interviews and three caregiver semi-structured interviews with lived experience of advanced kidney disease and frailty. Interviews were recorded, transcribed, and coded for meaningful concepts and analysed using inductive thematic analysis using constant comparative method of data analysis employing Social Cognitive Theory., Results: Six major themes emerged including accommodating frailty is an act of resilience, exercise is endorsed for rehabilitation but existing programs have failed to meet end-users' needs. Rehabilitation goals were framed around return to normative behaviours and rehabilitation should have a social dimension, offering understanding for "people like us". Participants reported on barriers and disruptors to frailty rehabilitation in the CKD context. Participants valued peer-to-peer education, the camaraderie of socialisation and the benefit of feedback for maintaining motivation. Patients undertaking dialysis described the commodity of time and the burden of unresolved symptoms as barriers to participation. Participants reported difficulty envisioning strategies for frailty rehabilitation, maintaining a focus on the immediate and avoidance of future uncertainty., Conclusions: Frailty rehabilitation efforts in CKD should leverage shared experiences, address comorbidity and symptom burden and focus on goals with normative value., (© 2024. Crown.)

Background: National guidance recognises the key role of rehabilitation in improving outcomes for people living with chronic kidney disease. Implementation of this guidance is reliant upon an adequate and skilled rehabilitation workforce. Data relating to this is currently lacking within the UK. This survey aimed to identify variations and good practices in kidney physiotherapy (PT), occupational therapy (OT) and clinical exercise physiologist (CEP) provision; and to understand barriers to implementation., Methods: An online survey was sent to all 87 UK kidney units between June 2022 and January 2023. Data was collected on the provision of therapy services, barriers to service provision and responses to the COVID-19 pandemic. The quantitative survey was analysed using descriptive statistics. Free-text responses were explored using reflexive thematic analysis., Results: Forty-five units (52%) responded. Seventeen (38%) units reported having a PT and 15 (33%) an OT with a specialist kidney role; one unit (7%) had access to a CEP. Thirty units (67%) offered inpatient therapy services, ten (22%) outpatient therapy clinics, six (13%) intradialytic exercise, six (13%) symptom management and three (7%) outpatient rehabilitation. Qualitative data revealed lack of money/funding and time (both n = 35, 85% and n = 34, 83% respectively) were the main barriers to delivering kidney-specific therapy. Responders saw an increase in the complexity of their caseload, a reduction in staffing levels and consequently, service provision during the COVID-19 pandemic. Exemplars of innovative service delivery, including hybrid digital and remote services, were viewed as positive responses to the COVID-19 pandemic., Conclusion: Despite clear evidence of the benefits of rehabilitation, across the UK, there remains limited and variable access to kidney-specific therapy services. Equitable access to kidney-specific rehabilitation services is urgently required to support people to 'live well' with kidney disease., (© 2024. The Author(s).)

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., Competing Interests: Conflict of interest: none declared., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: The increasing prevalence of chronic kidney disease (CKD) requires effective preventive measures, particularly due to an aging population. This study aimed to assess the effectiveness of home visit rehabilitation in preventing renal function decline among patients with CKD., Method: In this retrospective study, patients with non-dialysis CKD undergoing home visit rehabilitation were compared with those receiving outpatient care at the Nippon Medical School Hospital between August 2017 and August 2023. Patients' backgrounds were matched using propensity scores derived from a logistic regression model. The primary endpoint was the annual change in the estimated glomerular filtration rate (eGFR), and the secondary endpoint was the annual change in blood parameters (Δblood urea nitrogen, Δcreatinine, Δtotal protein, Δalbumin, ΔC-reactive protein, Δhemoglobin, and Δhematocrit). Furthermore, the incidence of clinical outcomes, including mortality, hospitalization rate, and dialysis initiation rate, were analyzed within the additional 1-year observation period., Results: Overall, 128 patients (64 matched pairs) were analyzed. After a mean follow-up period of 12.7 ± 4.6 months, there was no significant difference in the eGFR between both groups (40.1 ± 13.7 vs. 37.8 ± 13.8 mL/min/1.73 m 2 , p = 0.36), but the annual decline in eGFR (%/year) was significantly lower in the rehabilitation group (-1.1 ± 29.8% vs. -11.8 ± 27.7%/year, p = 0.037). The annual change in the level of each blood test parameter and clinical outcomes were not significantly different between the two groups., Conclusion: Home-based rehabilitation interventions may mitigate the progression of renal impairment in patients with CKD.

Background: As the geriatric population is growing rapidly, so is the prevalence of chronic kidney disease (CKD). Suitable rehabilitation programs are needed to decrease disability and improve functionality to maintain independence in activities of daily life., Aims: To assess the impact of CKD on the efficacy of rehabilitation in the geriatric population., Methods: Retrospective single-center cohort study, demographic and clinical data of 190 elderly, non-dialysis dependent CKD patients, who underwent rehabilitation, during 2016-2020 were analyzed., Results: Early CKD patients had longer duration of rehabilitation as compared with advanced CKD (32.6 ± 19.5 vs. 25.1 ± 17.6 days, p = 0.011) and tended to be more independent at discharge (37.2% vs. 27.9%, respectively; p < 0.001). Duration of rehabilitation, Mini-Mental State Examination (MMSE), Functional Independence Measurement (FIM) admission and estimated GFR were important predictors of FIM at discharge. Age was negatively correlated with admission FIM, eGFR, MMSE, and discharge FIM. The odds ratio for mortality among patients with advanced as compared to early CKD was 2.197 (CI 95% 1.159-4.166, p = 0.015)., Discussion: Existing rehabilitation programs raise questions of suitability for the consistently aging population, play an indispensable part in the goal of achieving functional independence in the elderly and should promote further investigation of the efficacy of rehabilitation for CKD patients., Conclusions: Advanced CKD was associated with lower FIM at admission and discharge, shorter duration of rehabilitation and more dependence at discharge, as compared to patients with early CKD. Implementing a multidisciplinary team, focused on the specific needs of geriatric CKD patients, with clear, objective parameters and goals may lead to better rehabilitative outcomes, with decreased public and private costs of ongoing care., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Aim: The burden of several cardiovascular risk factors increases in parallel to renal function decline. Exercise intolerance is common in patients with chronic kidney disease (CKD) and has been associated with increased risk of adverse outcomes. Whether indices of cardiorespiratory capacity deteriorate with advancing CKD stages is unknown., Methods: We conducted a systematic review and meta-analysis of studies assessing cardiorespiratory capacity in adult patients with pre-dialysis CKD using cardiopulmonary exercise testing (CPET) and reporting data for different stages. Our primary outcome was differences in peak oxygen uptake (VO 2 peak) between patients with CKD Stages 2-3a and those with Stages 3b-5(pre-dialysis). Literature search was undertaken in PubMed, Web of Science and Scopus databases, and abstract books of relevant meetings. Quality assessment was undertaken with Newcastle-Ottawa-Scale., Results: From 4944 records initially retrieved, six studies with 512 participants fulfilling our inclusion criteria were included in the primary meta-analysis. Peak oxygen uptake (VO 2 peak) was significantly higher in patients with CKD Stages 2-3a versus those with Stages 3b-5(pre-dialysis) [weighted-mean-difference, WMD: 2.46, 95% CI (1.15, 3.78)]. Oxygen consumption at ventilatory threshold (VO 2 VT) was higher in Stages 2-3a compared with those in Stages 3b-5(pre-dialysis) [standardized-mean-difference, SMD: 0.59, 95% CI (0.06, 1.1)], while no differences were observed for maximum workload and respiratory-exchange-ratio. A secondary analysis comparing patients with CKD Stages 2-3b and Stages 4-5(pre-dialysis), yielded similar results [WMD: 1.78, 95% CI (1.34, 2.22)]. Sensitivity analysis confirmed the robustness of these findings., Conclusion: VO 2 peak and VO 2 VT assessed with CPET are significantly lower in patients in CKD Stages 3b-5 compared with Stages 2-3a. Reduced cardiorespiratory fitness may be another factor contributing to cardiovascular risk increase with advancing CKD., (© 2021 Asian Pacific Society of Nephrology.)

Background: Exercise improves health outcomes and quality of life in persons with chronic kidney disease (CKD). The numbers of persons with advanced CKD meeting physical activity guidelines however is low. We undertook a qualitative study of men and women aged 36-74 from various race/ethnic populations with advanced CKD not requiring dialysis to describe their experiences and opinions around prior physical activity, motivating factors for and barriers to exercise, and perceptions of exercise-promoting technology and group-based programming designed to improve physical activity levels., Methods: Nineteen persons with advanced CKD not requiring dialysis were interviewed at two high volume nephrology clinics enriched with racial/ethnic minority patients (Emory University and Santa Clara Valley Medical Center). We used thematic analysis to identify dominant themes (n = 4) and subthemes (n = 19) around exercise experience, barriers, motivators, views, and preferences., Results: Four dominant themes and 19 subthemes were identified. The most common motivators to exercise included physical and mental health benefits, appearance, improvement in energy levels, and potential social interaction in group-based programs. Common barriers included health concerns, particularly complications related to other co-morbidities, as well as time and transportation constraints. Participants were skeptical of exercise programs solely reliant on technology., Conclusions: The use of group-based exercise programs may motivate persons with CKD to increase exercise levels, while programs entirely based on technology may be less effective., (© 2021. The Author(s).)

Introduction: Chronic kidney disease (CKD) is characterized by adverse physical function. Mechanical muscle power describes the product of muscular force and velocity of contraction. In CKD, the role of mechanical muscle power is poorly understood and often overlooked as a target in rehabilitation. The aims of this study were to investigate the association of mechanical power with the ability to complete activities of daily living and physical performance., Method: Mechanical muscle power was estimated using the sit-to-stand-5 test. Legs lean mass was derived using bioelectrical impedance analysis. Physical performance was assessed using gait speed and 'timed-up-and-go' (TUAG) tests. Self-reported activities of daily living (ADLs) were assessed via the Duke Activity Status Index. Balance and postural stability (postural sway and velocity) was assessed using a FysioMeter. Sex-specific tertiles were used to determine low levels of power., Results: One hundred and two non-dialysis CKD participants were included (age: 62.0 (±14.1) years, n = 49 males (48%), eGFR: 38.0 (±21.5) ml/min/1.73m 2 ). The mean relative power was 3.1 (±1.5) W/kg in females and 3.3 (±1.3) W/kg in males. Low relative power was found in 34% of patients. Relative power was an independent predictor of ADLs (β = .413, p = .004), and TUAG (β = -.719, p < .001) and gait speed (β = .404, p = .003) performance. Skeletal muscle mass was not associated with any outcomes., Conclusion: Knowledge of the factors that mediate physical function impairment is crucial for developing effective interventions. Incorporation of power-based training focusing primarily on movement velocity may present the best strategy for improving physical function in CKD, above those that focus on increasing muscle mass., (© 2021 Asian Pacific Society of Nephrology.)

Introduction: Chronic kidney disease is associated with an increased risk of vascular events and bone fractures, and its prevalence is increasing. Despite the high frequency of strokes and bone fractures in the hemodialysis (HD) population, the few studies on rehabilitation outcomes in this population are controversial. The current study assessed the efficacy of inpatient rehabilitation for hemodialysis patients., Methods: This is a retrospective, observational review of medical records of all chronic HD patients who underwent rehabilitation in Meir Medical Center, from 2008 to 2018. The primary endpoint was functional independence measure (FIM) score at discharge. Secondary endpoints were all-cause mortality, efficiency of rehabilitation and discharge destination from rehabilitation., Results: During the study period, 162 patients were included in the analysis. 76/81 (93.8%) hemodialysis patients had improvement FIM scores. There were no significant differences in FIM scores at discharge between hemodialysis patients and controls. However, the efficiency of rehabilitation expressed by FIM efficiency (progress measured as FIM gain/length of stay in rehabilitation) was higher in hemodialysis vs. controls. 73% of hemodialysis patients were discharged home. There was no significant difference in discharge destinations between groups. Both 30-day and 1-year mortality after admission to rehabilitation was higher in HD vs. controls (OR 4.97, 95% CI 1.4-18.2, p = 0.008 and OR 4.98, 95% CI 1.8-14.1, p value = 0.001, respectively)., Conclusion: Hemodialysis patients may benefit from inpatient rehabilitation. Although mortality was higher, efficacy of rehabilitation for hemodialysis patients is comparable to non-dialysis patients and is no less effective.

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.

Background: The burden of chronic kidney disease (CKD) and its treatment may severely limit the ability of children with CKD to do daily tasks and participate in family, school, sporting and recreational activities. Life participation is critically important to affected children and their families; however, the appropriateness and validity of available measures used to assess this outcome are uncertain. The aim of this study was to identify the characteristics, content and psychometric properties of existing measures for life participation used in children with CKD., Methods: We searched MEDLINE, Embase, PsychINFO, Cumulative Index to Nursing and Allied Health Literature and the Cochrane Kidney and Transplant register to August 2019 for all studies that used a measure to report life participation in children with CKD. For each measure, we extracted and analyzed the characteristics, dimensions of life participation and psychometric properties., Results: From 128 studies, we identified 63 different measures used to assess life participation in children with CKD. Twenty-five (40%) of the measures were patient reported, 7 (11%) were parent proxy reported and 31 (49%) had both self and parent proxy reports available. Twenty-two were used in one study only. The Pediatric Quality of Life Inventory version 4.0 generic module was used most frequently in 62 (48%) studies. Seven (11%) were designed to assess ability to participate in life, with 56 (89%) designed to assess other constructs (e.g. quality of life) with a subscale or selected questions on life participation. Across all measures, the three most frequent activities specified were social activities with friends and/or family, leisure activities and self-care activities. Validation data in the pediatric CKD population were available for only 19 (30%) measures., Conclusions: Life participation is inconsistently measured in children with CKD and the measures used vary in their characteristics, content and validity. Validation data supporting these measures in this population are often incomplete and are sparse. A meaningful and validated measure for life participation in children with CKD is needed., (© The Author(s) 2020. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.)

Background: Chronic Kidney Disease (CKD) patients frequently develop life-impairing bone mineral disorders. Despite the reported impact of exercise on bone health, systematic reviews of the evidence are lacking. This review examines the association of both physical activity (PA) and the effects of different exercise interventions with bone outcomes in CKD., Methods: English-language publications in EBSCO, Web of Science and Scopus were searched up to May 2019, from which observational and experimental studies examining the relation between PA and the effect of regular exercise on bone-imaging or -outcomes in CKD stage 3-5 adults were included. All data were extracted and recorded using a spreadsheet by two review authors. The evidence quality was rated using the Cochrane risk of bias tool and a modified Newcastle-Ottawa scale., Results: Six observational (4 cross-sectional, 2 longitudinal) and seven experimental (2 aerobic-, 5 resistance-exercise trials) studies were included, with an overall sample size of 367 and 215 patients, respectively. Judged risk of bias was low and unclear in most observational and experimental studies, respectively. PA was positively associated with bone mineral density at lumbar spine, femoral neck and total body, but not with bone biomarkers. Resistance exercise seems to improve bone mass at femoral neck and proximal femur, with improved bone formation and inhibited bone resorption observed, despite the inconsistency of results amongst different studies., Conclusions: There is partial evidence supporting (i) a positive relation of PA and bone outcomes, and (ii) positive effects of resistance exercise on bone health in CKD. Prospective population studies and long-term RCT trials exploring different exercise modalities measuring bone-related parameters as endpoint are currently lacking.

Objectives: Combined aerobic and resistance exercise (CARE) is beneficial for improving renal function. To confirm this, we conducted a meta-analysis to evaluate the effects of CARE on renal function in adult patients with chronic kidney disease (CKD)., Date Sources: The last date of search was 22 February 2020. We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Allied and Complementary Medicine (AMED), CINAHL, Web of Science, SPORTDiscus, and three Chinese databases (China National Knowledge Infrastructure (CNKI), Wangfang, Journal Integration Platform (VIP)) for articles of randomized and quasi-randomized controlled trials., Methods: We used the Cochrane tool and the JBI Critical Appraisal checklist to assess randomized controlled trials and quasi-randomized controlled trials, respectively., Result: A total of 12 studies and 745 patients were included. Compared with usual care or no exercise, CARE resulted in a significant improvement in the estimated glomerular filtration rate (between-group analysis: mean difference (MD) =5.01, 95% confidence interval (CI): 2.37 to 7.65; within-group analysis: MD = 3.01, 95% CI: 0.86 to 5.16). The serum creatinine levels also showed a significant improvement after CARE (between-group analysis: MD = -8.57, 95% CI: -13.71 to -3.43; within-group analysis: MD = -6.33, 95% CI: -10.23 to -2.44). Patients who performed CARE also demonstrated a decline in the blood pressure in the within-group analysis (systolic blood pressure: MD = -5.24, 95% CI: -7.93 to -2.54; diastolic blood pressure: MD = -3.63, 95% CI: -5.35 to -1.91). However, there were no significant differences in proteinuria, lipid levels, physical composition, and quality of life., Conclusion: The study results support the concept that CARE intervention improves renal function. It provides strong evidence for guiding clinical decisions and implementing renal rehabilitation exercises.

Intradialytic exercise (ID) programs are effective and safe for hemodialysis (HD) patients to avoid functional deterioration. However, exercise is not routinely undertaken in most HD units, and we do not know if home-based (HB) programs are as effective as ID programs. The purpose of this study was to compare the effects of 16 weeks of ID exercise versus a HB exercise program for HD patients. A total of 46 patients were randomly assigned to the ID group (n = 24) or HB group (n = 22). They completed a 16-week combined exercise program 3 times/week. We measured physical activity level, physical functioning, depression level, and health-related quality of life at baseline and after 16 weeks. A significant time effect was found in both groups for the physical activity level (p = 0.012). There was also a significant group-time interaction effect for the one-leg standing test (OLST) (p = 0.049) and a significant time effect for the Short Physical Performance Battery (p = 0.013), timed up-and-go test (p = 0.005), sit-to-stand-10 (p = 0.027), right and left hand handgrip (p = 0.044, p < 0.001), one-heel left leg raise (p = 0.019), and 6-minute walking (p = 0.006), depression (p = 0.017). HRQoL remained unchanged. There was no difference between the two interventions on the tested outcomes (besides OLST). Both interventions were associated with positive changes of the physical activity levels and physical function.

Background: Rehabilitation effects of exercise training on adults with chronic kidney disease (CKD) have been generally recognised; however, the effects of exercise training on proteinuria have been underexplored. Our aim was to explore the effects of exercise training on proteinuria in adult CKD patients without renal replacement therapy., Methods: Randomised controlled trials (RCTs) and quasi-experimental studies examining the effects of exercise training on proteinuria in adults CKD patients without renal replacement therapy were searched in 10 electronic databases (MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine Database, SPORTDiscus with full text, Web of Science, China Wan Fang Database, China National Knowledge Internet, China Science and Technology Journal Database) until June 2019. The quality of quasi-experimental studies was assessed using the Joanna Briggs Institute Checklist for non-randomised experimental studies. The Cochrane risk of bias tool was used to evaluate the RCT quality., Results: We analysed 11 studies (623 participants). The 24-h urinary protein (24 h UP) level significantly decreased after exercise training in the within-group analysis (standard mean difference [SMD], 0.48; 95% confidence interval [CI], 0.08 to 0.88). There was a slight decrease in 24 h UP levels in the between-group analysis (SMD, 0.91; 95% CI, 0.00 to 1.82); however, the subgroup analysis showed that the change was insignificant (RCT: SMD, 0.24; 95% CI, - 0.44 to 0.92; quasi-experimental studies: SMD, 2.50; 95% CI, - 1.22 to 6.23). Exercise resulted in no significant differences in the urinary albumin-to-creatinine ratio in the between-group analysis (SMD, 0.06; 95% CI, - 0.54 to 0.67), but a significant decrease was found in the within-group analysis (SMD, 0.21; 95% CI, 0.04 to 0.38). No evidence of a decreased urinary protein-to-creatinine ratio was found after exercise (between-group analysis: SMD, 0.08 and 95% CI, - 0.33 to 0.48; within-group analysis: SMD, 0.04; 95% CI, - 0.25 to 0.32)., Conclusion: Exercise training does not aggravate proteinuria in adult CKD patients without renal replacement therapy. Further research is warranted in the future to determine the effectiveness of exercise training on proteinuria and to explore the mechanisms by which exercise training influences proteinuria.

Background: For patients with CKD, evidence on the optimal dose of physical activity and possible harm with excessive exercise is limited. This study aimed to analyze the dose-response association between leisure-time physical activity (LTPA) and mortality in those with CKD and explore the optimal dose or possible harm associated with increased levels of LTPA., Methods: 4,604 participants with CKD from the 1999 to 2012 National Health and Nutrition Examination Surveys with linked mortality data obtained through 2015 were classified into 6 groups: 0, 1-149, 150-299, 300-599, 600-899, and ≥900 min/week based on the total duration of the self-reported LTPA. Multivariable-adjusted Cox proportional hazards models were used to examine dose-response associations between LTPA and mortality., Results: During the median follow-up of 114 months, 1,449 (31%) all-cause deaths were recorded. Compared to the inactive group (0 min/week), we observed a 22% lower risk of all-cause mortality (hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.63-0.97) among participants who performed 1-149 min per week for LTPA. The corresponding HRs and 95% CIs for all-cause mortality for 150-299 and 300-599 min/week of LTPA were 0.79 (0.64-0.97) and 0.74 (0.56-0.98). The benefit appeared to reach a threshold of a 43% (HR, 0.57; 95% CI, 0.36-0.91) lower risk of all-cause mortality among individuals performing 600-899 min/week for LTPA. Importantly, for ≥900 min/week of LTPA, the continued benefits were observed (HR, 0.62; 95% CI, 0.44-0.87)., Conclusion: LTPA was associated with lower mortality in those with CKD. The optimal dose was observed at the LTPA level of approximately 600-899 min/week, and there were still benefits rather than the excess risk with LTPA levels as high as ≥900 min/week. Therefore, clinicians should encourage inactive CKD patients to perform LTPA and do not need to discourage CKD patients who already adhere to long-term physical activity., (© 2020 S. Karger AG, Basel.)

Background: Despite the abundance of data documenting the consequences of poor sleep quality on blood pressure (BP), no previous study to our knowledge has addressed the impact of sleep improvement on resistant hypertension among patients with chronic kidney disease (CKD)., Methods: The aim of this pilot study was to determine whether improved sleep quality and duration will improve BP control in patients with resistant hypertension and CKD. It was a prospective single-center cohort study that involved 30 hypertensive subjects with CKD presenting with primary resistant hypertension and poor sleep quality or duration <6 h/night. Sleep quality and duration were modified using either sleep hygiene education alone or adding sleep medication. The cohort's BP was followed every 3 months for 6-month duration. The average home and clinic BPs were collected at each follow-up visit. The primary outcome baseline change in systolic BP (SBP) and diastolic BP (DBP; home and clinic) at 3 and 6 months after documented sleep improvement. Secondary outcomes included change from baseline in mean arterial pressure, and delta SBP after sleep improvement., Results: African American patients represented 50% of the cohort. All patients had evidence of CKD with GFR ≤60 mL/min and were obese with 40% having type 2 diabetes mellitus. The primary endpoint of change in clinic SBP and DBP was significantly reduced at 3 months, baseline 156 ± 15/88 ± 8 vs. 3 months 125 ± 14/73 ± 7 (p < 0.0001). This difference persisted at 6 months. However, there was no further reduction in-home or clinic BPs between the 3- and 6-month periods. Home and clinic average delta SBP change at 3 months from baseline was -34.4 ± 15 and -30.8 ± 19 mm Hg respectively. Delta SBP change was associated with sleep improvement of >6 h/night, that is, gaining an extra 3-4 h' sleep duration, home; R2 = 0.66, p < 0.0001 and clinic; R2 = 0.49, p < 0.0001., Conclusion: Optimizing sleep quality and duration to >6 h/night improved BP control and was associated with a significant delta change in SBP within 3 months of follow-up. Physicians should obtain a sleep history in patients with CKD who present with resistant hypertension., (© 2020 S. Karger AG, Basel.)

Background: Chronic kidney disease (CKD) is frequently present in patients with aortic valve disease. Decreased kidney perfusion as a consequence of reduced cardiac output may contribute to renal dysfunction in this setting., Objective: Given the potential reversibility of kidney hypoperfusion after valve repair, this study aimed to analyze the impact of percutaneous transcatheter aortic valve implantation (TAVI) on kidney function., Methods: We performed a retrospective analysis of 233 consecutive patients who underwent TAVI in a single center between November 2008 and May 2016. We assessed three groups according to their baseline estimated glomerular filtration rate (eGFR) (mL/min/1.73 m2): Group 1 with eGFR ≥ 60; Group 2 with 30 ≤ eGFR < 60; and Group 3 with eGFR < 30. We analyzed the eGFR one month and one year after TAVI in these three groups, using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula to calculate it., Results: Patients from Group 1 had a progressive decline in eGFR one year after the TAVI procedure (p < 0.001 vs. pre-TAVI). In Group 2 patients, the mean eGFR increased one month after TAVI and continued to grow after one year (p = 0.001 vs. pre-TAVI). The same occurred in Group 3, with the mean eGFR increasing from 24.4 ± 5.1 mL/min/1.73 m2 before TAVI to 38.4 ± 18.8 mL/min/1.73 m2 one year after TAVI (p = 0.012)., Conclusions: For patients with moderate-to-severe CKD, kidney function improved one year after the TAVI procedure. This outcome is probably due to better kidney perfusion post-procedure. We believe that when evaluating patients that might need TAVI, this 'reversibility of CKD effect' should be considered.

Objectives: The aim of the study was to compare the effects of a physical activity program on daily physical activity and quality of life in kidney transplant (KTx) recipients and in patients with chronic kidney disease (CKD)., Materials and Methods: The study group consisted of 24 KTx recipients and 15 patients with stage 3 to 4 CKD. Habitual physical activity was monitored for 72 hours. Individualized structured programs of increased physical activity were prepared based on baseline physical performance. The measurements were repeated after 1 and 3 months. Participants completed the 36-item Short Form Health Survey questionnaire and an International Physical Activity Questionnaire at baseline and after 1, 2, and 3 months., Results: Physical activity duration and total energy expenditure significantly increased after 3 months in both KTx recipients (from 126 ± 87 to 200 ± 132 min/d, P = .001, and from 1.73 ± 0.37 to 2.24 ± 0.59 cal/min, P < .001, respectively) and CKD patients (from 79 ± 78 to 129 ± 114 min/d, P < .001, and from 1.5 ± 0.5 to 1.92 ± 0.47 cal/min, P < .001, respectively). Short Form Health Survey total score and physical component scale score improved significantly in both groups. Mental component scale score increased significantly only in KTx patients., Conclusion: Increased physical activity induces similar beneficial effects on total and physical activity component of quality of life and habitual daily activity in CKD and KTx patients., (Copyright © 2019. Published by Elsevier Inc.)

Physical function is an important outcome in chronic kidney disease (CKD). We aimed to establish the reliability, validity, and the "minimal detectable change" (MDC) of several common tests used in renal rehabilitation and research. In a repeated measures design, 41 patients with CKD not requiring dialysis (stage 3b to 5) were assessed at an interval of 6 weeks. The tests were the incremental shuttle walk test (ISWT), "sit-to-stand" (STS) test, estimated 1 repetition maximum for quadriceps strength (e1RM), and VO 2peak by cardiopulmonary exercise testing (CPET). Reliability was assessed using intraclass correlation coefficient and Bland-Altman analysis, and absolute reliability by standard error of measurement and MDC. The ISWT, STS-60, e1RM, and CPET had "good" to "excellent" reliability (0.973, 0.927, 0.927, and 0.866), respectively. STS-5 reliability was poor (0.676). The MDC is ISWT, 20 m; STS-5, 7.5 s; STS-60, 4 reps; e1RM, 6.4 kg; VO 2peak , 2.8 ml/kg/min. There was strong correlation between the ISWT and VO 2peak (r = 0.73 and 0.74). While there was poor correlation between the STS-5 and e1RM (r = 0.14 and 0.47), better correlation was seen between STS-5 and ISWT (r = 0.55 and 0.74). In conclusion, the ISWT, STS-60, e1RM, and CPET are reliable tests of function in CKD. The ISWT is a valid means of exercise capacity. The MDC can help researchers and rehabilitation professionals interpret changes following an intervention.

Objective: Chronic kidney disease patients are characterized by impaired physical function. The goal of exercise-based interventions is an improvement in functional performance. However, improvements are often determined by "statistically significant" changes. We investigated the "minimum clinically important difference," "the smallest change that is important to the patient," for commonly reported physical function tests., Design: Nondialysis chronic kidney disease patients completed 12-wks of a combined aerobic (plus resistance training). The incremental shuttle walking test, sit-to-stand 5 and 60, estimated 1-repetition maximum for the knee extensors, and VO2peak were assessed. After the intervention, patients rated their perceived change in health. Both anchor- and distribution-based minimum clinically important difference approaches were calculated., Results: The minimum clinically important difference was calculated as follows: incremental shuttle walking test, +45 m; sit-to-stand 5, -4.2 secs; VO2peak, +1.5 ml/kg per min. Because of comparable increases in "anchor" groups, no minimum clinically important difference was estimated for the sit-to-stand 60 or estimated 1-repetition maximum., Conclusions: We have established the minimum clinically important difference in chronic kidney disease for common tests of physical function. These values represent the minimum change required for patients to perceive noticeable and beneficial change to their health. These scores will help interpret changes after exercise interventions where these tests are used. These minimum clinically important differences can be used to power future studies to detect clinically important changes., To Claim Cme Credits: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Define the "minimum clinically important difference"; (2) Distinguish between concepts of minimum clinically important difference, "minimal detectable change,", and "statistically significant change"; and (3) Interpret other study findings and their own results in the context of the minimum clinically important difference rather than statistically significant changes., Level: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Background: Twelve weeks of renal rehabilitation (RR) have been shown to improve exercise capacity in patients with chronic kidney disease (CKD); however, survival following RR has not been examined., Methods: This study included a retrospective longitudinal analysis of clinical service outcomes. Programme completion and improvement in exercise capacity, characterised as change in incremental shuttle walk test (ISWT), were analysed with Kaplan-Meier survival analyses to predict risk of a combined event including death, cerebrovascular accident, myocardial infarction and hospitalisation for heart failure in a cohort of patients with CKD. Time to combined event was examined with Kaplan-Meier plots and log rank test between 'completers' (attended >50% planned sessions) and 'non-completers'. In completers, time to combined event was examined between 'improvers' (≥50 m increase ISWT) and 'non-improvers' (<50 m increase). Differences in time to combined event were investigated with Cox proportional hazards models (adjusted for baseline kidney function, body mass index, diabetes, age, gender, ethnicity, baseline ISWT and smoking status)., Results: In all, 757 patients (male 54%) (242 haemodialysis patients, 221 kidney transplant recipients, 43 peritoneal dialysis patients, 251 non-dialysis CKD patients) were referred for RR between 2005 and 2017. There were 193 events (136 deaths) during the follow-up period (median 34 months). A total of 43% of referrals were classified as 'completers', and time to event was significantly greater when compared with 'non-completers' (P = 0.009). Responding to RR was associated with improved event-free survival time (P = 0.02) with Kaplan-Meier analyses and log rank test. On multivariate analysis, completing RR contributed significantly to the minimal explanatory model relating clinical variables to the combined event (overall χ2 = 38.0, P < 0.001). 'Non-completers' of RR had a 1.6-fold [hazard ratio = 1.6; 95% confidence interval (CI) 1.00-2.58] greater risk of a combined event (P = 0.048). Change in ISWT of >50 m contributed significantly to the minimal explanatory model relating clinical variables to mortality and morbidity (overall χ2 = 54.0, P < 0.001). 'Improvers' had a 40% (hazard ratio = 0.6; 95% CI 0.36-0.98) independent lower risk of a combined event (P = 0.041)., Conclusions: There is an association between completion of an RR programme, and also RR success, and a lower risk of a combined event in this observational study. RR interventions to improve exercise capacity in patients with CKD may reduce risk of morbidity and mortality, and a pragmatic randomised controlled intervention trial is warranted., (© The Author(s) 2018. Published by Oxford University Press on behalf of ERA-EDTA.)

The past two decades have witnessed tremendous progress in our understanding of the mechanisms underlying wasting and cachexia in chronic kidney disease (CKD) and in other chronic illnesses, such as cancer and heart failure. In all these conditions wasting is an effect of the activation of protein degradation in muscle, a response that increases the risk of morbidity and mortality. Major recent advances in our knowledge on how CKD and inflammation affect cellular signaling include the identification of the myostatin (MSTN)/activin system, and its related transcriptional program that promotes protein degradation. In addition, the identification of the role of MSTN/activin in the vascular wall shows premise that its inhibition can better control or prevent some effects of CKD on vessels, such as accelerated atherosclerosis and vascular calcifications. In this review, we summarize the expanding role of MSTN activation in promoting muscle atrophy and the recent clinical studies that investigated the efficacy of MSTN/activin pathway antagonism in sarcopenic patients. Moreover, we also review the utility of MSTN inhibition in the experimental models of CKD and its potential advantages in CKD patients. Lessons learned from clinical studies on MSTN antagonism in sarcopenic patients tell us that the anabolic intervention is likely better if we use a block of the two ActRII receptors. At the same time, however, it is becoming clear that MSTN-targeted therapies should not be seen as a substitute for physical activity and nutritional supplementation which are mandatory to successfully manage patients with wasting., (Copyright © 2018 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Management of hypertension in chronic kidney disease (CKD) remains a major challenge. We conducted a systematic review to assess whether exercise is an effective strategy for lowering blood pressure in this population., Design, Setting, Participants, and Measurements: We searched MEDLINE, EMBASE, the Cochrane Library, CINAHL and Web of Science for randomized controlled trials (RCTs) that examined the effect of exercise on blood pressure in adults with non-dialysis CKD, stages 3-5. Outcomes were non-ambulatory systolic blood pressure (primary), other blood pressure parameters, 24-hour ambulatory blood pressure, pulse-wave velocity, and flow-mediated dilatation. Results were summarized using random effects models., Results: Twelve studies with 505 participants were included. Ten trials (335 participants) reporting non-ambulatory systolic blood pressure were meta-analysed. All included studies were a high risk of bias. Using the last available time point, exercise was not associated with an effect on systolic blood pressure (mean difference, MD -4.33 mmHg, 95% confidence interval, CI -9.04, 0.38). The MD after 12-16 and 24-26 weeks of exercise was significant (-4.93 mmHg, 95% CI -8.83, -1.03 and -10.94 mmHg, 95% CI -15.83, -6.05, respectively) but not at 48-52 weeks (1.07 mmHg, 95% CI -6.62, 8.77). Overall, exercise did not have an effect on 24-hour ambulatory blood pressure (-5.40 mmHg, 95% CI -12.67, 1.87) or after 48-52 weeks (-7.50 mmHg 95% CI -20.21, 5.21) while an effect was seen at 24 weeks (-18.00 mmHg, 95% CI -29.92, -6.08). Exercise did not have a significant effect on measures of arterial stiffness or endothelial function., Conclusion: Limited evidence from shorter term studies suggests that exercise is a potential strategy to lower blood pressure in CKD. However, to recommend exercise for blood pressure control in this population, high quality, longer term studies specifically designed to evaluate hypertension are needed., Competing Interests: The authors have declared that no competing interests exist.

Depressive symptom is the most frequent psychological problem reported among chronic kidney disease (CKD) patients being treated by hemodialysis. This article evaluates the effectiveness of multidisciplinary rehabilitation on depressive symptoms in hemodialysis patients and clarifies the role of nurses. This quasi-experimental study was done on 30 patients in the hemodialysis center (educational hospital) in 2013. Eight rehabilitation plans were conducted by nurses. Beck Depression Inventory (BDI) was used before and after intervention. Our data were analyzed using descriptive and inferential statistics. Result of this study shows that there was a significant difference between mean depressive symptom score before (36.4 ± 10.9) and after (10.5 ± 3.1) rehabilitation ( p < .001). It is recommended that rehabilitation program be implemented in all hemodialysis centers with the participation of specialists in different fields.

Introduction: Chronic kidney disease can lead to dysfunction of the respiratory, cardiac, and musculoskeletal systems, altering the body's metabolism. Renal transplantation and hospital physiotherapy, through specific protocols, can improve these dysfunctions., Objectives: This study evaluates the impact of a hospital physiotherapeutic protocol in quality of life (QoL), respiratory muscle strength, peak expiratory flow, and 6-minute walk test (6MWT) in the preoperative, first, and fifth days after renal transplantation., Methods: We evaluated 39 patients who received a renal transplant at Clinics Hospital of University of Campinas for respiratory muscle strength, expiratory peak flow, and functional capacity by the 6MWT. The short form-36 quality of life questionnaire was applied to 12 patients., Results: We observed a significant reduction in respiratory muscle strength and peak expiratory flow in the first postoperative day. On postoperative day 5, there was improvement in respiratory muscle strength and expiratory peak flow. However, aerobic capacity measured by 6MWT remained below predicted. Analysis of QoL showed an improvement in almost all analyzed domains after transplantation., Conclusion: A specific physiotherapeutic protocol applied early after transplantation provided recovery of respiratory muscle strength and QoL. However, longer training is necessary to obtain adequate aerobic rehabilitation., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: Patients with chronic kidney disease (CKD) display increased infection-related mortality and elevated cardiovascular risk only partly attributed to traditional risk factors. Patients with CKD also exhibit a pro-inflammatory environment and impaired immune function. Aerobic exercise has the potential to positively impact these detriments, but is under-researched in this patient population. This feasibility study will investigate the effects of acute aerobic exercise on inflammation and immune function in patients with CKD to inform the design of larger studies intended to ultimately influence current exercise recommendations., Methods and Analysis: Patients with CKD, including renal transplant recipients, will visit the laboratory on two occasions, both preceded by appropriate exercise, alcohol and caffeine restrictions. On visit 1, baseline assessments will be completed, comprising anthropometrics, body composition, cardiovascular function and fatigue and leisure time exercise questionnaires. Participants will then undertake an incremental shuttle walk test to estimate predicted peak O 2 consumption (VO 2 peak). On visit 2, participants will complete a 20 min shuttle walk at a constant speed to achieve 85% estimated VO 2 peak. Blood and saliva samples will be taken before, immediately after and 1 hour after this exercise bout. Muscle O 2 saturation will be monitored throughout exercise and recovery. Age and sex-matched non-CKD 'healthy control' participants will complete an identical protocol. Blood and saliva samples will be analysed for markers of inflammation and immune function, using cytometric bead array and flow cytometry techniques. Appropriate statistical tests will be used to analyse the data., Ethics and Dissemination: A favourable opinion was granted by the East Midlands-Derby Research Ethics Committee on 18 September 2015 (ref 15/EM/0391), and the study was approved and sponsored by University Hospitals of Leicester Research and Innovation (ref 11444). The study was registered with ISRCTN (ref 38935454). The results will be presented at relevant conferences, and it is anticipated that the reports will be published in appropriate journals in 2018., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: To compare the effect of conventional physical therapy and Pilates on function, restoration, and exercise ability in hospitalized chronic renal patients., Methods: A total of 56 inpatients were randomized into two groups: Conventional physical therapy and Pilates. The primary outcomes were functionality (Barthel Index), respiratory muscle strength (manovacuometry), and ability to exercise (step test) evaluated in the following periods: preintervention, after the 5th session, and after the 10th session or at discharge. Three months after randomization, the Barthel Index was applied over the phone. At the end of the 10 sessions or at discharge, the length of hospital stay was calculated and the level of satisfaction with physical therapy care was assessed (MedRisk). Linear mixed models were used for the primary outcomes and the Student's t-test was used for length of stay and satisfaction., Results: There was no significant between-group difference in functionality (MD -1.3; 95% CI -2.8 to 5.4), inspiratory and expiratory muscle strength (MD -1.3; 95% CI -7.3 to 4.5/MD -4.5; 95% CI -0.7 to 9.7, respectively), performance in the step test (MD -3.3; 95% CI -6.2 to 12.8), patient satisfaction with physical therapy care (MD -2.0; 95% CI -5.1 to 9.1), and length of stay (MD 4.5; 95% CI -15.9 to 6.8)., Conclusion: Both interventions, conventional physical therapy and Pilates, showed improvements and there is no difference between them. Therefore both can be used in chronic renal patients.

Background: Major adverse cardiac and cerebrovascular event (MACCE) is one of most common complications of hemodialysis patients. Heart rate variability (HRV) is the predictor of death in heart disease patients. However, there are no studies on the role of HRV in hemodialysis patients., Methods: From September 2009 to March 2011, 24-h electrocardiography was performed in 101 hemodialysis patients. Standard deviation of sequential 5-minute N-N interval means (SDANN) and standard deviation of the N-N interval (SDNN) was examined by a 24-h ECG analysis. Patients were observed prospectively. The primary endpoints were incidence of MACCE and MACCE-free survival., Results: We studied 90 hemodialysis patients (64 males, 63.4 ± 11.8 years old). During a follow-up period of 32.0 ± 11.7 months, 33 patients developed MACCE. 24-h ECG showed mean SDNN 93.4 ± 33.4 ms and mean SDANN 83.2 ± 31.3 ms. MACCE group showed significantly lower SDNN and SDANN than event-free group. In Kaplan-Meier analysis higher SDNN and SDANN group showed significantly higher event-free survival rate than lower group. Using a Cox proportional hazards model, SDNN was independent prognostic factor while SDANN or diabetic status was not significant. In diabetic cases, there were no differences in any factors for the incidence of MACCE between higher SDNN, SDANN groups and lower groups. On the other hand in non-diabetic cases, lower SDNN or SDANN group developed significantly higher MACCE than higher groups., Conclusion: Measurement of HRV by Holter ECG is useful to predict MACCE in hemodialysis patients, especially non-diabetic group.

Introduction: Improved survival of chronic kidney disease (CKD) patients has led to an increased focus on health-related quality of life (HRQoL) for evaluating treatment effectiveness and assessing health outcomes of these patients., Objective: To evaluate HRQoL in patients in different stages of CKD and to explore possible correlating and influencing factors., Methods: Cross-sectional design with 200 patients from India in CKD stages 1-5 assessed for HRQoL through 36-item short-form together with biomarkers. Patients were divided into four groups according to their estimated Glomerular Filtration Rate (eGFR); group A with GFR range > 90 ml/min/1.73 m 2 , group B with GFR range 30-59 ml/min/1.73 m 2 , group C with GFR range 15-29 ml/min/1.73 m 2 and group D with GFR < 15 ml/min/1.73 m 2 RESULTS: HRQoL scores in all dimensions impaired progressively and significantly across renal function levels and CKD stages. A statistically significant decreasing trend in physical composite summary and mental composite summary scores was found in patients from group A to D (P< 0.001). Patients with eGFR < 30 ml/min/1.73 m 2 , Diabetes Mellitus, Cardio vascular disease (CVD), C-reactive protein (CRP) ≥ 5 mg/l, Hemoglobin  ≤ 90 g/l, erythrocyte sedimentation rate  ≥ 20 and mean arterial pressure  ≥ 100 mm hg had significantly lower scores on all HRQoL dimensions. Among these CRP, reduced GFR and CVD were the most important predictors of impaired HRQoL., Conclusion: Considering the worldwide growing prevalence of CKD and increasing importance of HRQoL in chronic diseases, improving our knowledge about HRQoL and its predictors in CKD patients is important. Assessment of HRQoL early in disease course will help to identify high risk patients in whom modifying these factors may help them lead an active and healthy life., (© The Author 2016. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Patients with chronic kidney disease can present compromised functional abilities, and hospitalization may further contribute to their health deterioration and loss of functional independence., Objectives: To compare the effectiveness between Pilates Method and Conventional Physical Therapy in functionality, exercise capacity and respiratory muscle strength in hospitalized patients with chronic kidney disease., Methods: 56 patients will be randomized into Control (usual care) or Pilates groups. Functionality (Barthel Index), exercise capacity (Step Test) and respiratory muscle strength (Manovacuometry) will be evaluated during pre-intervention, after the 5th and 10th sessions or at discharge in both groups. The statistical analysis will be calculated using linear mixed models and based on intention-to-treat. The level of significance will be set at α = 5%. This study is the first to develop a Pilates protocol for hospitalized chronic renal failure patients and the results will provide additional treatment options for these patients and for physiotherapists., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

In the general population, moderate exercise is associated with several health benefits including a decreased risk of obesity, coronary heart disease, stroke, certain types of cancer and all-cause mortality. In chronic kidney disease (CKD), physical inability is an independent risk of death. Health benefits of regular exercise in CKD patients include improvements in functional and psychological measures such as aerobic and walking capacity and health-related quality of life. Nonetheless, in CKD patients exercise rehabilitation is not routinely prescribed. Renal patients are heterogeneous across the different stages of CKD so that the assessment of physical capability is mandatory for a correct exercise program prescription. To plan appropriate exercise programs in the CKD setting, targeted professional figures should be actively involved as many psychological or logistic barriers may hamper exercise implementation in these subjects. Different approaches, such as home exercise rehabilitation programs, supervised exercise training or in-hospital gym may theoretically be proposed. However, physical exercise should always be tailored to the individual capacity and comorbidities and each patient should ideally be involved in the decision-making process.

Background: Home-based exercise has been shown to provide benefits in terms of physical capacity in the general population, but has been scarcely investigated in patients with chronic kidney disease (CKD)., Aims: To evaluate the impact of a home-based aerobic training on the cardiopulmonary and functional capacities of overweight non-dialysis-dependent patients with CKD (NDD-CKD)., Methods: Twenty-nine sedentary patients (55.1 ± 11.6 years, BMI = 31.2 ± 6.1 kg/m(2), eGFR = 26.9 ± 17.4 mL/min/1.73 m(2)) were randomly assigned to a home-based exercise group (n = 14) or to a control group (n = 15) that remained without performing exercise. Aerobic training was performed three times per week for 12 weeks. A cardiopulmonary exercise test, functional capacity and clinical parameters were evaluated., Results: A significant increase, ranging from 8.3 to 17 %, was observed in the cardiopulmonary capacity parameters, such as maximal ventilation (p = 0.005), VO2peak (p = 0.049), ventilatory threshold (p = 0.040) and respiratory compensation point (p < 0.001), of the exercise group. A simultaneous improvement in the functional capacity tests [6-min walk test (p < 0.001), time up and go test (p < 0.001), arm curl test (p < 0.001), sit and stand test (p < 0.001), 2-min step test (p < 0.001) and back scratch test (p = 0.042)] was also found in patients who were submitted to the exercise. Exercised patients experienced a decrease in systolic and diastolic blood pressure, average 10.6 % (p < 0.001) and 9.2 % (p = 0.007), respectively, and a trend toward improved renal function (p = 0.1). No change in any parameter was found in the control group during the follow-up., Conclusion: The home-based aerobic exercise program was feasible, safe and effective for the improvement in the cardiopulmonary and functional capacities of overweight NDD-CKD patients.

Aim: To compare the short version of International Physical Activity Questionnaire (IPAQ) and the accelerometer measurement of physical activity (PA) in patients undergoing hemodialysis., Methods: Sample consisted of 40 patients (19 men) aged 45 ± 16 years. Patients reported their PA using the IPAQ during a face-to-face interview, and wore an Actigraph GT3-X accelerometer for 1 week to obtain minutes per day of light PA, moderate-to-vigorous PA (MVPA) and total PA as well as raw counts per day (vector magnitude)., Results: All PA-related variables were significantly correlated among instruments (r = 0.34-0.47) when analyzed as a group. However, when analyzed separately by gender, the relationships were present for women only (r = 0.46-0.62). IPAQ significantly underestimated light PA (IPAQ vs. accelerometer: 180.0 vs. 251.1 min/day, p = 0.019), but no differences were found between methods for MVPA and total PA., Conclusion: Modest correlations were found between self-reported PA time by IPAQ (short version) and accelerometer, but only in women. However, the IPAQ may underestimate light PA, which is the main form of PA in this population., (© 2015 S. Karger AG, Basel.)

Chronic Kidney Disease (CKD) is a long-term progressive condition affecting 10-15% of people. The overlap of diabetes, hypertension and CKD in an aging population means that prevalence will only increase. CKD increases the risk of all-cause mortality, secondary to the elevated cardiovascular risk. It also significantly affects the patients' ability to engage in functional activities and their quality of life. The evidence base suggests that exercise has the capacity to improve symptom burden, functional ability and mental health. The majority of the patient population are pre-dialysis yet previous research has concentrated on dialysing patients. This review will focus on the patient group not requiring renal replacement therapy (non-RRT) as this is an area where further work is urgently needed. A large majority of people with CKD tend to be inactive despite emerging guidelines emphasising the positive effect of exercise for both people with chronic disease and healthy populations. This paper will review the evidence to support exercise to improve outcomes and quality of life and report on common barriers that patients experience and advocate the need for supported exercise interventions to help patients become more active and gain the potential resultant health benefits.

Chronic kidney disease (CKD) is becoming a serious health problem throughout the world and is one of the most potent known risk factors for cardiovascular disease, which is the leading cause of morbidity and mortality in this patient population. Physical inactivity has emerged as a significant and independent risk factor for accelerated deterioration of kidney function, physical function, cardiovascular function and quality of life in people in all stages of CKD. CKD specific research evidence, combined with the strong evidence on the multiple health benefits of regular and adequate amounts of PA in other cardiometabolic conditions, has resulted in physical inactivity being identified by national and international CKD clinical practice guidelines as one of the multiple risk factors that require simultaneous and early intervention for optimum prevention/management of CKD. Despite this realisation, physical inactivity is not systematically addressed by renal care teams. The purpose of this expert statement is therefore to inform exercise and renal care specialists about the clinical value of exercise therapy in CKD, as well as to provide some practical recommendations on how to more effectively translate the existing evidence into effective clinical practice.

Background and Objectives: Patients with CKD have a high prevalence of cardiovascular disease associated with or exacerbated by inactivity. This randomized, controlled study investigated whether a renal rehabilitation exercise program for patients with stages 3 or 4 CKD would improve their physical function and quality of life., Design, Setting, Participants, & Measurements: In total, 119 adults with CKD stages 3 and 4 were randomized, and 107 of these patients proceeded to usual care or the renal rehabilitation exercise intervention consisting of usual care plus guided exercise two times per week for 12 weeks (24 sessions). Physical function was determined by three well established performance-based tests: 6-minute walk test, sit-to-stand test, and gait-speed test. Health-related quality of life was assessed by the RAND 36-Item Short Form Health Survey., Results: At baseline, no differences in self-reported level of activity, 6-minute walk test, and sit-to-stand test scores were observed between the usual care (n=48) and renal rehabilitation exercise (n=59) groups, although baseline gait-speed test score was higher in the renal rehabilitation exercise group (P<0.001). At follow-up, the renal rehabilitation exercise group but not the usual care group showed significant improvements in the 6-minute walk test (+210.4±266.0 ft [19% improvement] versus -10±219.9 ft; P<0.001), the sit-to-stand test (+26.9±27% of age prediction [29% improvement] versus +0.7±12.1% of age prediction; P<0.001), and the RAND-36 physical measures of role functioning (P<0.01), physical functioning (P<0.01), energy/fatigue levels (P=0.01), and general health (P=0.03) and mental measure of pain scale (P=0.04). The renal rehabilitation exercise regimen was generally well tolerated., Conclusions: A 12-week/24-session renal rehabilitation exercise program improved physical capacity and quality of life in patients with CKD stages 3 and 4. Longer follow-up is needed to determine if these findings will translate into decreased mortality rates., (Copyright © 2014 by the American Society of Nephrology.)

Background: Chronic kidney disease (CKD) is a frequent comorbidity among elderly patients and those with cardiovascular disease. CKD carries prognostic relevance. We aimed to describe patient characteristics, risk factor management and control status of patients in cardiac rehabilitation (CR), differentiated by presence or absence of CKD., Design and Methods: Data from 92,071 inpatients with adequate information to calculate glomerular filtration rate (GFR) based on the Cockcroft-Gault formula were analyzed at the beginning and the end of a 3-week CR stay. CKD was defined as estimated GFR <60 ml/min/1.73 m(2)., Results: Compared with non-CKD patients, CKD patients were significantly older (72.0 versus 58.0 years) and more often had diabetes mellitus, arterial hypertension, and atherothrombotic manifestations (previous stroke, peripheral arterial disease), but fewer were current or previous smokers had a CHD family history. Exercise capacity was much lower in CKD (59 vs. 92 Watts). Fewer patients with CKD were treated with percutaneous coronary intervention (PCI), but more had coronary artery bypass graft (CABG) surgery. Patients with CKD compared with non-CKD less frequently received statins, acetylsalicylic acid (ASA), clopidogrel, beta blockers, and angiotensin converting enzyme (ACE) inhibitors, and more frequently received angiotensin receptor blockers, insulin and oral anticoagulants. In CKD, mean low density lipoprotein cholesterol (LDL-C), total cholesterol, and high density lipoprotein cholesterol (HDL-C) were slightly higher at baseline, while triglycerides were substantially lower. This lipid pattern did not change at the discharge visit, but overall control rates for all described parameters (with the exception of HDL-C) were improved substantially. At discharge, systolic blood pressure (BP) was higher in CKD (124 versus 121 mmHg) and diastolic BP was lower (72 versus 74 mmHg). At discharge, 68.7% of CKD versus 71.9% of non-CKD patients had LDL-C <100 mg/dl. Physical fitness on exercise testing improved substantially in both groups. When the Modification of Diet in Renal Disease (MDRD) formula was used for CKD classification, there was no clinically relevant change in these results., Conclusion: Within a short period of 3-4 weeks, CR led to substantial improvements in key risk factors such as lipid profile, blood pressure, and physical fitness for all patients, even if CKD was present., (© Authors 2013.)

Chronic kidney disease (CKD) patients not yet in dialysis can benefit from increased physical activity; however, the safety and outcomes of aquatic exercise have not been investigated in observational studies. The aim of this study was to analyze association of 10 years of regularly performed aquatic exercise with the study endpoint--that is, all-cause death or start of dialysis. Consecutive CKD patients were included in the study in January 2002. The exercise group (n=7) exercised regularly under the supervision of physiotherapist for 10 years; the control group (n=9), matched in terms of age and clinical parameters, remained sedentary. Low-intensity aerobic aquatic exercise was performed regularly twice a week; 32 weeks or more of exercise therapy sessions were conducted annually. None of the members of the aquatic exercise group reached dialysis or died in 10 years. In the sedentary control group, 55% reached the study endpoint--renal replacement therapy (n=2) or all-cause death (n=3). Occurrence of the study endpoint, compared using the exact multinomial test with unconditional margins, was statistically significantly different (P-value: 0.037) between the study groups. Regular supervised aquatic exercise arrested CKD progression. There was a statistically significant difference between the sedentary group and the exercise group in reaching renal replacement therapy or all-cause death in a follow-up time of 10 years.

Background: Whether exercise can affect health outcomes in people with chronic kidney disease (CKD) and what the optimal exercise strategies are for patients with CKD remain uncertain., Study Design: Systematic review and meta-analysis of randomized controlled trials., Setting & Population: Adults with CKD stages 2-5, dialysis therapy, or a kidney transplant., Selection Criteria for Studies: Trials evaluating regular exercise training outcomes identified by searches in Cochrane CENTRAL, MEDLINE, EMBASE, CINAHL, Web of Science, BIOSIS, PEDro, AMED, AgeLine, PsycINFO, and KoreaMed, without language restriction., Intervention: Regular exercise training for at least 8 weeks., Outcomes: Vary by study but could include aerobic capacity, muscular functioning, cardiovascular function, walking capacity, and health-related quality of life. Treatment effects were summarized as standardized difference with 95% CIs using random-effects meta-analysis., Results: 41 trials (928 participants) comparing exercise training with sham exercise or no exercise were included; overall, improved aerobic capacity, muscular functioning, cardiovascular function, walking capacity, and health-related quality of life were associated with various exercise interventions, although the preponderance of data were for dialysis patients and used aerobic exercise programs., Limitations: Unclear or high risk of bias in 32% of the trials, few trial data concerning resistance training, and limited data for several important outcomes., Conclusions: Regular exercise training generally is associated with improved health outcomes in individuals with CKD. Correctly designed exercise rehabilitation may be an effective part of care for adults with CKD. Future studies should examine longer term outcomes and strategies to translate exercise done in a supervised setting to the home setting for broader applicability., (Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

The practice of physical activity is now a subject of special attention in public health. Indeed, the expected benefits in terms of cardiovascular morbidity and mortality suggest that all physicians should promote it. However, there are few data on the impact of physical activity on the health of patients with chronic kidney disease before the dialysis stage. This review focuses on the relationship between chronic kidney disease and the practice of physical activity. Different tools to assess the level of physical activity helped to highlight a marked deterioration in physical capacity of patients with chronic kidney disease, including during the earliest stages. Although there is currently no specific recommendations regarding the practice of physical activity in patients with renal impairment, it seems desirable to promote it in an appropriate way, based on what is currently advocated for cardiovascular prevention in the general population., (Copyright © 2013 Association Société de néphrologie. Published by Elsevier SAS. All rights reserved.)

Background: The appropriate exercise counseling for chronic kidney disease (CKD) patients is crucial to improve their prognosis. There have been few studies about exercise counseling by primary care physicians for CKD patients. We investigated primary care physicians' exercise counseling practices for CKD patients, and the association of these physicians' own exercise habits with exercise counseling., Methods: The population of this cross-sectional study was 3310 medical doctors who graduated from Jichi Medical University from 1978 to 2012. The study instrument was a self-administered questionnaire that was mailed in August 2012 to investigate their age class, specialty, workplace, exercise habits, and practices of exercise counseling for CKD., Results: 581 (64.8%) medical doctors practiced the management of CKD among a total of 933 responses. These 581 medical doctors were defined as CKD primary care physicians and their answers were analyzed. CKD primary care physicians' own exercise habits (frequencies and intensities) were as follows: frequencies: daily, 71 (12.1%); ≥ 2-3 times/week, 154 (26.5%); ≥ 1 time/week, 146 (25.1%); and ≤ 1 time/month, 176 (30.2%); intensities: high (≥ 6 Mets), 175 (30.1%); moderate (4-6 Mets), 132 (22.7%); mild (3-4 Mets), 188 (32.3%); very mild (<3 Mets), 47 (8.1%); and none, 37 (6.4%). The CKD primary care physicians' exercise recommendation levels for CKD patients were as follows: high, 31 (5.3%); moderate, 176 (29.7%); low, 256 (44.0%); and none, 92 (15.8%). The CKD primary care physicians' exercise recommendations for CKD patients were significantly related to their own exercise frequency (p < 0.001), but they were not related to their age, specialty, workplace, or exercise intensity., Conclusions: CKD primary care physicians' exercise recommendation level for CKD patients was limited. In addition, CKD primary care physicians' own exercise habits influenced the exercise counseling for CKD patients. The establishment of guidelines for exercise by CKD patients and their dissemination among primary care physicians are needed.(University Hospital Medical Information Network Clinical Trial Registry. number, UMIN000011803. Registration date, Sep/19/2013).

The current investigation examined whether patients undergoing hemodialysis (HD) have reduced standing postural control performance during simultaneous cognitive task performance (i.e. dual task cost (DTC)) compared to age-gender matched controls. 19 persons undergoing HD and 19 age, gender, and body mass index (BMI) matched controls participated in the investigation. All participants performed 2 trials of quiet standing balance and 2 postural trials in which they performed a cognitive task. Postural control was indexed with various measures of the center of pressure (COP) trajectory. The change in postural control with a cognitive task (e.g. dual task cost DTC) was quantified as a change in the center of COP parameters of postural control from quiet standing to the cognitive condition. The primary observations were that (1) HD patients had significantly greater postural sway than age, gender, BMI matched controls (p's < 0.05); (2) HD patients had a greater DTC than the controls during quiet standing (p's < 0.05). The observations highlight that HD participants have poor postural control that is further exacerbated by a simultaneous performance of a cognitive task. It is possible that this impaired postural control places HD participants at elevated fall risk. Further study is necessary to determine contributing factors to an increased DTC in this population and whether targeted interventions such as exercise can reduce DTC., (Copyright © 2013 Elsevier B.V. All rights reserved.)