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Is well known that physical activity reduces rate of cardiovascular and all-cause mortality in the general population and in transplanted recipients. However, most of those investigations present limits. Few data are available on exercise effectiveness on kidney and liver transplant recipients and the correlation between practising exercise, lipid profile and renal function. Additionally, the knowledge on the amount of safe training for sport competitions for this population is limited. This thesis aims to increase the knowledge on the type of exercise and training adapted for transplant recipients and its relative effects on aerobic capacity, strength and quality of life. Moreover, correlation between exercise and blood pressure parameters in solid organ transplant are considered for safeguard of the graft function. The first part of this thesis focuses on the effects of exercise in kidney and liver transplant recipients by health pathways. The second part focus on the sport in solid organ transplant recipients to break down the prejudice that “transplantation” and “sport” cannot coexist. In detail, we investigate the renal function, metabolic profile, glycemia and the physical fitness after 12 months of supervised aerobic and resistance training in kidney and liver transplant recipients, compared with not supervised home-based physical activity. The results of these studies can provide information on the beneficial effects of combined exercise and identify the type of safe exercise to prescribe for the kidney and liver transplant population. These indications are intended to encourage the healthcare world to refer pre-and post-transplant patients to follow a healthy lifestyle including regular exercise for the prevention of cardiovascular diseases. To obtain more adherence in the prescription of exercise in transplant patients a study promote the network in which transplant centers, sports medicine centers and certified gyms collaborate to encourage the practice of prescribed and controlled exercise in pre- and post-transplant patients.

Background Few studies have evaluated the changes in renal function of transplant recipients (TR) after intense physical activity. Methods The purpose of this study was to investigate some aspects of renal function in TR participating in a road cycling race (CR) of 130km long (total climb: 1871m, uphill 50km, downhill 46km and 34km flat). Venous blood and urine samples were collected: i) the day before (Pre), ii) at the finish (Post), iii) 24 hours (24h) after CR from 20TR (mean±SD age 52±10yrs, 72±11kg, 173±0cm, 24.1±2.9kg/m2), who underwent transplant (2 heart, 5 liver, 11 kidney, 2 bone marrow) 8.8±4.9yrs before. Forty-four healthy subjects (HS) (52±9yrs, 73±9kg, 175±0cm, 23.8±2.2kg/m2) participating to the same race were recruited as control group. From the group of TR, we also collected data from 6 TR who have participated in two editions (2012-2013) of the same race. Results All the participants completed CR without problems. No significant differences were found in the mean race time in both groups (6.36.49±1.15.14 vs 6.03.27±0.47.24 hh.mm.ss). Significant differences were found between Pre-Post and Post-24h in TR and HS in urea (Pre 45±14, Post 68±20, 24h 62±16 vs Pre 38±8, Post 55±11, 24h 51±7 mg/dL; P

This article summarizes the published data and several practical experiences of organ transplant patients who practice sports, with the purpose of giving a picture which can help to understand the real performance possibilities of these patients and any limitations and/or contraindications to practising competitive sports. Literature indicates that solid organ (heart, liver, kidney) transplant recipients who practice competitive sports show good tolerance to immunosuppressive therapy, good function of the transplanted organ at rest and under exertion, good overall physical condition as a result of training, and a positive perception of their psycho-physical condition. In transplant recipients, the risks connected with sports are those of infection and cardiometabolic risks due to the side-effects of immunosuppression. The first is tackled with suitable prophylactic measures (personal hygiene, vaccinations). The second is tackled primarily with personalised exercise and used as a drug and also suitable pharmacological therapies. Traumatological risk does not appear to be hazardous for the transplanted organ, even in several contact sports such as football and basketball. There is evidence of transplant recipients who have returned to practice sports at the same level as that before the illness which had led them to the transplant, succeeding in competing on a par with healthy athletes of the top or Master category, while we are not aware of transplant recipients who have reported negative consequences for the transplanted organ because they practice sport, even at competitive levels. Transplant recipients who practice sports at an amateur or professional level cannot be considered representative of the entire population of transplant recipients, but they do offer a unique opportunity to become acquainted with the higher limits of the possibilities of functional recovery after a transplant. This aspect should be considered to formulate the criteria for granting fitness for competitive sports and, above ali, it allows to use these experiences to contrast the belief according to which transplants and sports cannot coexist.

Physical performance of kidney transplanted patients in challenging environments, such as deserts, has been poorly studied. Six kidney transplanted (T: 5 males, 1 female; 45±6 yrs) and 8 control (C: 5 males, 3 females; 49±13 yrs) subjects participated in a 5-day desert trek. Blood pressure, hydration status (Height2/Rz by bioimpedance), heart rate, energy expenditure (by SenseWear Pro Armband) and walking velocities were recorded during each daily trekking stage (GPS-assisted wearable devices). Systo-diastolic blood pressure did not differ between C (119/77±12/8 mmHg) and T (121/77±10/6 mmHg) groups throughout the study. The hydration status was stable from day 1 (Ht2/Rz: 64±13 cm2/Ohm in T and 59±12 cm2/Ohm in C subjects) to day 5 (66±11 cm2/Ohm in T and 61±13 cm2/Ohm in C subjects) in both groups. Two patients on steroid treatment showed a relative hyperhydration. Mean heart rate did not differ between T (135±10 bpm) and C (136±5 bpm) subjects throughout the study, although a reduction from day 1 to day 5 was observed in T subjects only (p 55 ml/min showed acceptable physical performance and acclimatization to desert environment, suggesting a good long-term outcome of transplantation

Background: Despite the benefits of physical activity on cardiovascular risk in kidney transplant recipients (KTRs), the long-term effects of exercise have been poorly investigated. This is a three-year observational study comparing graft function and cardiovascular risk factors in active KTRs (AKTRs) vs. sedentary KTRs (SKTRs). Methods: KTRs with stable renal function were assigned to active or sedentary group in relation to the level of daily physical activity based on World Health Organization (WHO) recommendations (&lt, 150 or &gt, 150 minutes/week, respectively). Complete blood count, renal function indices, lipid profile, blood pressure and anthropometric measures were collected yearly for an observation period of three years. The comparisons between the two groups were performed by repeated measures analyses of covariance (ANCOVAs), with age as a covariate. Results: Fifty-four subjects were included in the study. Thirty of them were identified as AKTRs (M/F 26/4, aged 45 &plusmn, 12 years) and 24 as SKTRs (M/F 18/6, aged 51 &plusmn, 14 years). Baseline characteristics were similar between the groups except body mass index (BMI) that was significantly higher in SKTRs (p = 0.043). Furthermore, over the three-year observation period, BMI decreased in AKTRs and increased in SKTRs (p = 0.006). Graft function was stable in AKTRs, while it showed a decline over time in SKTRs, as indicated by the rise in serum creatinine levels (p = 0.006) and lower eGFR (p = 0.050). Proteinuria, glucose and uric acid levels displayed a decrease in AKTRs and an increase in SKTRs during the three-year period (p = 0.015, p = 0.004 and p = 0.013, respectively). Finally, concerning lipid profiles, AKTRs had a significant reduction over time of triglycerides levels, which conversely showed a clinically relevant increase in SKTRs (p = 0.014). Conclusions: Our findings indicate that regular weekly exercise training may counteract the increased cardiovascular risks and also prevent graft function decline in KTRs.

Bartolomei, S, Totti, V, Griggio, F, Malerba, C, Ciacci, S, Semprini, G, and Di Michele, R. Upper-body resistance exercise reduces time to recover after a high-volume bench press protocol in resistance-trained men. J Strength Cond Res 35(2S): S180-S187, 2021-The aim of this study was to compare the effects of active and passive strategies on the recovery response after a high-volume bench press protocol. Twenty-five resistance-trained men (mean ± SD: age = 25.8 ± 3.6 years; body mass = 87.1 ± 12.1 kg; and height = 177.4 ± 4.9 cm) performed a high-volume bench press session (8 sets of 10 reps at 70% of 1 repetition maximum). Subsequently, they were randomly assigned to an active recovery (AR) group (n = 11) or to a passive recovery (PR) group (n = 14). Active recovery consisted of light bench press sessions performed 6 hours and 30 hours after the high-volume exercise protocol. Muscle performance (bench throw power [BTP] and isometric bench press [IBP]) and morphology (muscle thickness of pectoralis major [PECMT] and of triceps brachii [TRMT]) were measured before exercise (baseline [BL]), and at 15-minute (15P), 24-hour (24P), and 48-hour (48P) post-exercise. Post-exercise recovery of both maximal strength and power was accelerated in AR compared with PR. Both BTP and IBP were significantly (p0.001) reduced at 15P and 24P in PR, whereas changes were significant (p0.001) at 15P only in AR. PECMT was still significantly (p = 0.015) altered from BL at 48P in PR, whereas changes were significant (p0.001) at 15P only in AR. No significant interactions (p0.05) between PR and AR were detected for TRMT and muscle soreness. The present results indicate that AR enhances the recovery rate after high-volume exercise sessions and may be included in resistance training programs to optimize muscle adaptations.

Background Following the positive experience of the national project “A transplant...and now it’s time for sport,” the Transplant Reference Center of the Emilia-Romagna Region has pursued the promotion of pre- and post-transplant physical exercise by developing a network. Methods The path involved the transplant centers and operative units (UU.OO) who wanted to target transplant and waiting list patients, who are clinically stable, to perform personalized exercise through a program (supervised or not) prescribed by a specialist in sports medicine. With the collaboration of the Collective Prevention and Public Health Service, the network was established, consisting of the sports medicine centers and the gyms that promote health for adapted physical activity (PS-AMA). To implement the network, training courses for all the professionals involved (doctors, nurses, exercise specialists) and operational meetings in the transplant centers-nephrology units with patients’ associations have been organized. Results To date, there are 14 transplant centers and UU.OO, 9 sports medicine centers, and 45 PS-AMA involved in this network. Seven training courses were organized with the participation of 193 health professionals. Since January 2016, there have been 65 transplanted patients and 5 patients on the waiting list who practice the prescribed exercise. Of these, 45 carry out supervised exercise in PS-AMA; 25 perform autonomous exercise. Each patient is monitored every 6 months. No problems related to the exercise performance were recorded. Conclusions The development of a network of professionals and associations is the key element to raise awareness of physical activity among transplanted and waiting-for-transplant patients, reducing the pathologies associated with a sedentary lifestyle.

AIM To evaluate the effect of a 12-mo supervised aerobic and resistance training, on renal function and exercise capacity compared to usual care recommendations. METHODS Ninety-nine kidney transplant recipients (KTRs) were assigned to interventional exercise (Group A; n = 52) and a usual care cohort (Group B; n = 47). Blood and urine chemistry, exercise capacity, muscular strength, anthropometric measures and health-related quality of life (HRQoL) were assessed at baseline, and after 6 and 12 mo. Group A underwent a supervised training three times per week for 12 mo. Group B received only general recommendations about home-based physical activities. RESULTS Eighty-five KTRs completed the study (Group A, n = 44; Group B, n = 41). After 12 mo, renal function remained stable in both groups. Group A significantly increased maximum workload (+13 W, P = 0.0003), V’O2 peak (+3.1 mL/kg per minute, P = 0.0099), muscular strength in plantar flexor (+12 kg, P = 0.0368), height in the countermovement jump (+1.9 cm, P = 0.0293) and decreased in Body Mass Index (-0.5 kg/m2, P = 0.0013). HRQoL significantly improved in physical function (P = 0.0019), physical-role limitations (P = 0.0321) and social functioning scales (P = 0.0346). No improvements were found in Group B. CONCLUSION Twelve-month of supervised aerobic and resistance training improves the physiological variables related to physical fitness and cardiovascular risks without consequences on renal function. Recommendations alone are not sufficient to induce changes in exercise capacity of KTRs. Our study is an example of collaborative working between transplant centres, sports medicine and exercise facilities.

Purpose: To describe cycling performance in a well-trained male a decade after Cardiac Transplantation (CTX). Case report: The patient was diagnosed with arrhythmo- genic right ventricular cardiomyopathy at 14 years of age and underwent CTX at 35 years. Exercise training began 3 weeks after CTX, and progressively increased in volume and intensity. Ten years after CTX he participated in twelve one-day cycling races over an eight-month period. Maximal cardiopulmonary exercise test was performed before the study. One race was monitored using a power meter. Results: VO2peak (47.2 mL/kg/min), maximal HR (161 bpm), and oxygen pulse (18.8 mL/bpm) were 113%, 92%, and 118% of age-predicted values respectively. HR, W, and relative VO2 at the ventilatory threshold and at the respira- tory compensation point were 128 bpm, 120 W, and 75% VO2peak, and 142 bpm, 155 W, and 86% VO2peak respec- tively. Cycling economy was ~80 W per liters per O2/min. The race was completed in 7 hours and 56 minutes, at an average of 141 bpm and 162 W, remaining between moder- ate-to-high intensity (4 h 2 min), and above high-to-severe intensity (2 h 19 min). Conclusion: Long-term aerobic training may result in a re- markable cycling performance a decade after CTX, likely because of cardiovascular adaptations.

Background/Aims: The role of physical activity in transplanted patients is often underestimated. We discuss the Italian National Transplant Centre experience, which started in 2008 studying transplanted patients involved in sports activities. The study was then developed through a model of cooperation between surgeons, sports physicians and exercise specialists. Methods: A multicentre study was realized in 120 transplanted patients of which 60 treated with supervised physical activity (three sessions/week of aerobic and strengthening exercises) and 60 controls. We present the results of the first 26 patients (16 males, 10 females; 47.8±10.0 years; 21 kidney, 5 liver transplanted; time from transplant 2.3±1.4 years) who completed 12 months of supervised physical activity. Results: Data showed an increase of peak aerobic power (t=4.535; PConclusion: These preliminary results confirm the positive effects of supervised physical exercise. It can be considered as an input to promote other detailed exercise protocols.

Background: A few patients, after receiving solid organ transplantation, return to performing various sports and competitions; however, at present, data no study had evaluated the effects of endurance cycling races on their renal function. Methods: Race times and short form (36) health survey questionnaires of 10 kidney transplant recipients (KTR) and 8 liver transplant recipients (LTR) transplanted recipients involved in a road cycling race (130 km) were compared with 35 healthy control subjects (HCS), also taking laboratory blood and urine tests the day before the race, at the end of the race, and 18 to 24 hours after competing. Results: The 3 groups showed similar race times (KTR, 5 hours 59 minutes ± 0 hours 39 minutes; LTR, 6 hours 20 minutes ± 1 hour 11 minutes; HCS, 5 hours 40 minutes ± 1 hour 28 minutes), similar short form (36) health survey scores, and similar trend of laboratory parameters which returned to baseline after 18 to 24 hours. After the race, there was an increase in creatinine (0.24 mg/dL; effect size [ES] = 0.78; P < 0.001), urea (22 mg/dL; ES = 1.42; P < 0.001), and a decrease of estimated glomerular filtration rate (−17 mL/min; ES = 0.85; P < 0.001). The increase of blood uric acid was more remarkable in HCS and KTR (2.3 mg/dL; ES = 1.39; P < 0.001). The KTR showed an increase of microalbuminuria (167.4 mg/L; ES = 1.20; P < 0.001) and proteinuria (175 mg/mL; ES = 0.97; P < 0.001) similar to LTR (microalbuminuria: 176.0 mg/L; ES = 1.26; P < 0.001; proteinuria: 213 mg/mL; ES = 1.18; P < 0.001), with high individual variability. The HCS had a nonsignificant increase of microalbuminuria (4.4 mg/L; ES = 0.03; P = 0.338) and proteinuria (59 mg/mL; ES = 0.33; P = 0.084). Conclusions: Selected and well-trained KTR and LTR patients can participate to an endurance cycling race showing final race times and temporary modifications of kidney function similar to those of HCS group, despite some differences related to baseline clinical conditions and pharmacological therapies. Patients involved in this study represent the upper limit of performance currently available for transplant recipients and cannot be considered representative of the entire transplanted population.