Chronic kidney disease

Reading time:

Research indicates that aerobic exercise, resistance training and concurrent training all have applications in for individuals with chronic kidney disease and may therefore be a useful addition to other treatment methods. Aerobic exercise seems primarily beneficial for improving blood pressure and aerobic capacity, as well as physical function and quality of life. Resistance training is effective for increasing or reducing the loss muscle mass in the face of a catabolic, low-protein diet in patients who would otherwise suffer marked muscular atrophy.

CONTENTS


What is chronic kidney disease?

Chronic kidney disease (CKD) is defined as occurring where an individual has either kidney damage for >3 months, as denoted by structural or functional abnormalities, or has a glomerular filtration rate (GFR) of <60 ml/min per 1.73m2 or a urinary albumin-to-creatinine ratio >30mg/g for >3 months (Levey et al.). Chronic kidney disease is generally discussed on a spectrum ranging from stages 1 – 5, as follows:

Stage GFR definition Other descriptive terms
Stage 1 GFR of >90 ml/min per 1.73m2 albuminuria, proteinuria, hematuria
Stage 2 GFR of 60 – 89 ml/min per 1.73m2 albuminuria, proteinuria, hematuria
Stage 3 GFR of 30 – 59 ml/min per 1.73m2 chronic renal insufficiency or early renal insufficiency
Stage 4 GFR of 15 – 29 ml/min per 1.73m2 chronic renal insufficiency or late renal insufficiency
Stage 5 GFR of <15 ml/min per 1.73m2 or dialysis renal failure, end-stage renal disease, uremia

It is slightly confusing that although stages 1 – 2 do not meet the criterion of a GFR of <60 ml/min per 1.73m2. However, other factors may be used to diagnose chronic kidney disease and therefore it is possible to have chronic kidney disease and still have a GFR of >60 ml/min per 1.73m2.

What is the prevalence of chronic kidney disease?

Measuring the prevalence of chronic kidney disease
The exact methodology used to assess kidney function, even where glomerular filtration rate (GFR) is used, can have a marked effect on the results. The two common methods used are The Modification of Diet in Renal Disease Study (MDRD) equation and the adjusted Cockcroft-Gault (CG) equation. Researchers have reported that the MDRD equation is more accurate for estimating GFR in both healthy populations and individuals with chronic kidney disease (Coresh and Stevens, Lin et al., Levey et al. and Lamb et al.). Researchers have also reported that MDRD consistently underestimates GFR (Coresh and Stevens, and Lin et al.) while CG consistently overestimates GFR (Lin et al.).

Prevalence of chronic kidney disease
A number of studies have assessed the prevalence of chronic kidney disease in various different populations, with varying results, depending on the age, race and geography of the individuals involved. The table below shows some of the detail:

Study Date Population Prevalence
Brown et al. 2003 US adults aged 18 – 101 years 15.6%
Cirillo et al. 2006 adults in central Italy aged 18 – 95 years 6.5%
Coresh et al. 2003 US adults 4.5%
Coresh et al. 2005 US adults 3.8%
Fox et al. 2005 US adults of mean age 59 years 8.6%
Garg et al. 2004 institutionalized elderly in Canada aged >65 years 35.7%
Hallan et al. 2006 Norwegian adults aged >20 years 4.7%
Hemmelgarn et al. 2006 elderly in Canada aged >66 years 35.4%
Kramer et al. 2005 US adults aged 30 – 65 years 1.5%
Manjunath et al. 2003 US adults aged >65 years 23.4%
McClellan et al. 2006 US adults aged >45 years 43.3%
Nitsch et al. 2006 Swiss adults aged >18 years 8.1%
Otero et al. 2005 Spanish adults aged >20 years 5.1%
Wasen et al. 2004 Finnish adults aged 64 – 100 years 35.8%

Based on the results shown in the table, we can see that older populations are much more likely to display chronic kidney disease than younger populations.


What are the risk factors for chronic kidney disease?

Several studies have assessed the risk factors for chronic kidney disease, as shown in the following table:

Study Description Finding
Haroun et al. The researchers carried out a prospective, observational study over a 20-year period in order to assess the associations between hypertension and smoking on the future risk of chronic kidney disease in 23,534 community-based subjects in Washington County, Maryland. The researchers reported that the risk of developing chronic kidney disease in normal, high-normal, stage 1 hypertension, stage 2 hypertension and stages 3 – 4 hypertension was 2.5, 3.0, 3.8, 6.3 and 8.8 times greater than optimal blood pressure in females and 1.4, 3.3, 3.0, 5.7, 9.7 times greater than optimal blood pressure in males. The researchers also noted that cigarette smoking was also significantly associated with risk of chronic kidney disease in both males and females.
Perneger et al. The researchers performed a case-control study to assess whether individuals with insulin-dependent diabetes and non-insulin-dependent diabetes were at a greater risk for end-stage renal disease than people without diabetes. The researchers found that individuals with insulin-dependent diabetes were 33.7 times more likely to incur end-stage renal disease, while individuals with non-insulin-dependent diabetes were 7.0 times more likely to incur end-stage renal disease. However, the risk was markedly affected by the length of time for which the individual had been suffering from diabetes, with longer periods associated with much greater risks of end-stage renal disease.
Brancati et al. The researchers performed a prospective cohort study in 332,544 US male adults aged 35 – 57 years to assess the association between diabetes mellitus as defined by self-reported use of medication and the risk of developing end-stage renal disease. The researchers found that the diabetic males were 12.7 times more likely to develop end-stage renal disease than the non-diabetic males.
Chen et al. The researchers performed a cross-sectional study to assess the association between the metabolic syndrome and the risk of developing chronic kidney disease. In this study, chronic kidney disease was defined as a glomerular filtration rate <60 mL/min per 1.73m2. The researchers found that individuals with the metabolic syndrome were 2.6 times more likely to have chronic kidney disease than those without the metabolic syndrome.
Klag et al. The researchers performed a longitudinal trial over an average follow-up period of 16 years to assess the development of end-stage renal disease in 332,544 men, 35 – 57 years of age. The researchers found a strong, graded relation between both systolic and diastolic blood pressure and the incidence of end-stage renal disease was identified. The researchers found that for males with stage 4 hypertension (systolic pressure >210mmHg or diastolic pressure >120mmHg) were 22.1 times more likely to incur end-stage renal disease  than males with an optimal level of blood pressure (systolic pressure <120mmHg and diastolic pressure <80mmHg).
Iseki et al. The researchers performed a prospective study in 107,192 Okinawan subjects >18 years of age to assess the risk factors associated with end-stage renal disease. The researchers found that individuals with high diastolic blood pressure were 1.39 times more likely to suffer from end-stage renal disease than those with normal diastolic blood pressure.
Gambaro et al. The researchers carried out a cross-sectional study to assess the effect of long-term cigarette smoking on renal function in 30 subjects who smoked and in 24 age- and sex-matched controls with no history of smoking. The researchers reported that in comparison with the non-smokers, the smokers had a renal function impairment characterized by a normal glomerular filtration rate but a significant reduction in renal plasma flow.
Hsu et al. The researchers performed a cohort study to assess the association between body mass index (BMI) as a proxy for overweight and obesity and the risk of developing end-stage renal disease in 320,252 adult members of Kaiser Permanente in California. The researchers reported that in comparison with individuals of normal BMI, overweight individuals (25 – 29.9kg/m2) had a 1.87 times greater risk of developing end-stage renal disease, class 1 obese individuals (30.0 to 34.9 kg/m2) had a 3.57 times greater risk of developing end-stage renal disease, class 2 obese individuals (35.0 to 39.9kg/m2) had a 6.12 times greater risk of developing end-stage renal disease, and extremely obese individuals (>40.0kg/m2) had a 7.07 times greater risk of developing end-stage renal disease.
Hsu et al. The researchers performed a cohort study to assess the association between body mass index (BMI) as a proxy for overweight and obesity and the risk of developing end-stage renal disease in 316,675 adult members of Kaiser Permanente in California. The researchers reported that in comparison with individuals with a blood pressure <120/80mmHg, individuals with blood pressures of 120 – 129/80 – 84mmHg, 130 – 139/85 – 89mmHg, 140 – 159/90 – 99mmHg, 160 – 179/100 – 109mmHg, 180 – 209/110 – 119mmHg and >210/120mmHg had a 1.62, 1.98, 2.59, 3.86, 3.88 and 4.25 times greater risk of developing end-stage renal disease.
Hsu et al. The researchers performed a 25-year follow-up to their cohort study to assess the risk factors for developing end-stage renal disease in 177,570 adult members of Kaiser Permanente in California. The researchers reported that the most important risk factors were proteinuria and overweight or obesity. They noted that individuals who displayed 3 – 4+, 1 – 2+ or trace of proteinuria had a 7.90, 3.59 and 2.37 times greater risk of developing end-stage renal disease than individuals who displayed a negative urine test. They noted that individuals who were overweight, class 1 or classes 2 – 3 obese had a 1.65, 3.11 and 4.39 times greater risk of developing end-stage renal disease than individuals who were normal weight.
Tozawa et al. The researchers performed a prospective study to assess the association between blood pressure and the risk of developing end-stage renal disease in 98,759 subjects, aged 20 – 98 years, in Okinawa, Japan. The researchers reported a significant positive association between both systolic and diastolic blood pressure and the risk of developing end-stage renal disease was 1.29 and 1.34 times greater for each 10mmHg of systolic blood pressure in males and females, respectively and was 1.56 and 1.69 times  greater for each 10mmHg of diastolic blood pressure in males and females, respectively.
Reynolds et al. The researchers performed a prospective cohort study of 158,365 Chinese males and females aged >40 years to assess the association between blood pressure and the risk of developing end-stage renal disease in an Asian population. The researchers reported that in comparison with individuals with normal blood pressure, individuals with pre-hypertension, stage 1 and stage 2 hypertension were 1.30 1.47 and 2.60 times more likely to develop end-stage renal disease.
Robinson-Cohen et al. The researchers performed a prospective cohort study of 4,011 community-dwelling US men and women aged >65 years in order to assess the association between physical activity and the rate of decline of kidney function. Physical activity score was calculated by reference to the sum of leisure-time activity and walking pace while decline in kidney function was defined as rapid where there was a loss of >3.0 mL/min per 1.73 m2 per year. The researchers found that the risk of rapid kidney function decline was 16% in the highest physical activity group and 30% in the lowest physical activity group. They reported that the two highest physical activity groups were associated with a 28% lower risk of rapid kidney function decline than the two lowest physical activity groups.
Hawkins et al. The researchers performed a cross-sectional population-based study to assess the association between time spent at all levels of physical activity intensity, sedentary behavior and kidney function. The researchers reported that both light and total physical activity was associated with the log of glomerular filtration rate in both females and males.
White et al. The researchers performed a prospective, population-based cohort study in order to assess the association between leisure-time physical activity and risk of chronic kidney disease in 6,318 Australians aged >25 years. The researchers reported that in comparison with individuals who undertook a minimum of 150 minutes of physical activity per week, inactive individuates were 1.34 times more likely to have albuminuria and obese, inactive individuals were 1.74 times more likely to have albuminuria.
Lynch et al. The researchers assessed both the cross-sectional and prospective relationships of television viewing time and biomarkers of chronic kidney disease. The researchers found that television viewing was significantly associated with increased odds of albuminuria and a low glomerular filtration rate.

Based on these studies, it appears that low levels of physical activity, sedentary behavior, being overweight or obese, diabetes, hypertension and smoking are all significant risk factors for chronic kidney disease.

Is aerobic exercise useful for chronic kidney disease?

A large number of studies have investigated the use of aerobic exercise interventions for the treatment of chronic kidney disease, as shown in the following table:

Study Description Finding
Boyce et al. The researchers assessed the effects of 4 months of aerobic exercise on cardiorespiratory function and endurance, blood pressure, hematology, blood lipids and renal function in 16 individuals with chronic renal failure who were not yet on dialysis. The researchers found that the aerobic exercise training did not affect hematology, blood lipids or echocardiographic measurements of left ventricular function and mass but it did improve measures of blood pressure, muscular strength and aerobic capacity.
Clyne et al. The researchers assessed the effects of 3 months of aerobic training in 19 pre-dialysis uremic patients (7 males and 3 females) aged 47 ± 8 years. The researchers found that the exercise group displayed significant increases in maximal exercise capacity, heart rate at sub-maximal exercise intensity and dynamic muscular endurance. However, total hemoglobin, blood volume, glomerular filtration rate, blood pressure and echocardiographic variables did not change.
Eidemak et al. The researchers performed a randomized controlled trial to assess the effects of aerobic exercise training on the progression of chronic renal failure in 30 patients with a median glomerular filtration rate (GFR) of 25 ml/min per 1.73m2. The researchers randomly allocated the subjects to either aerobic exercise comprising 30 minutes of stationary cycling per day or to maintenance of their usual lifestyle. The researchers found that median maximal work capacity increased significantly in the aerobic exercise group but was unchanged in the control group. However, the researchers did not detect any effect of the exercise on progression of renal disease as measured by GFR.
Fitts et al. The researchers assessed the effects of aerobic exercise on various measures of physical function and quality of life in pre-dialysis and dialysis patients. The researchers found that the exercise pre-dialysis group displayed significant improvements in 6-minute walking distance and symptoms, while the combined exercise pre-dialysis and dialysis group displayed significant improvements in hematocrit. The researchers concluded that quality of life was stable or improved in the pre-dialysis exercise group but declined in the pre-dialysis control group. They concluded that the pre-dialysis exercise group benefited more from the exercise training than the dialysis exercise group.
Heiwe et al. The researchers assessed the effects of 12 weeks of muscular endurance training on thigh muscle function, walking capacity and physical function in 16 elderly pre-dialysis patients aged 76 ± 7 years with a glomerular filtration rate of 18 ± 5 ml/min per 1.73m2. The researchers reported that muscular strength, dynamic muscular endurance, walking capacity, and physical function all increased significantly but there was no alteration in either static muscular endurance or quality of life. The researchers also reported that the improvements were not significantly different to those observed in healthy subjects of a similar age.
Kosmadakis et al. The researchers performed a prospective study to assess the benefits of 6 months of walking in 40 pre-dialysis patients with stages 4 – 5 chronic kidney disease. The researchers randomly allocated the subjects into either a walking exercise group or to a control group who just performed their usual physical activity. The researchers reported that the walking exercise group displayed significant improvements in exercise tolerance, weight loss, cardiovascular reactivity, avoiding an increase in blood pressure medication, quality of life and symptom scores.
Leehey et al. The researchers performed a randomized controlled feasibility study to assess the effects of a 24-week aerobic exercise program in 11 patients with type 2 diabetes, obesity (defined by a body mass index (BMI) > 30 kg/m2), and stage 2 – 4 chronic kidney disease (as defined by a glomerular filtration rate (GFR) of 15 – 90 mL/min per 1.73m2 combined with proteinuria). The exercise program involved aerobic training 3 times per week. The researchers reported that the aerobic exercise group displayed a significant increase in exercise duration during treadmill testing, non-significant improvements in resting systolic blood pressure and 24-hour proteinuria and no changes in GFR, hemoglobin, glycated hemoglobin, serum lipids and C-reactive protein levels.
Pechter et al. The researchers assessed the effects of 12 weeks of low-intensity aerobic, aquatic exercise on cardiorespiratory, renal lipid parameters and oxidative stress status in patients with mild-to-moderate renal failure. The exercise group performed 30-minute sessions, 2 times per week while the control group remained sedentary. The researchers reported that the exercise group displayed improvements in cardiorespiratory function, resting blood pressure, proteinuria, cystatin-C and glomerular filtration rate.
Goldberg et al. The researchers performed an uncontrolled trial to assess the effects of 9 ± 6 months of aerobic exercise training on lipid and carbohydrate metabolism in 6 patients undergoing hemodialysis. The aerobic exercise training involved cycle ergometer, walking, jogging and calisthenics at 65 – 75% of maximum heart rate (HR-max) to the point of tolerance. The researchers reported that the aerobic exercise training led to reduced triglyceride levels, increased plasma high-density lipoprotein cholesterol levels, improved glucose tolerance, reduced hyperinsulinism, increased hematocrits and reduced requirement for antihypertensive medications but did not lead to any significant changes in bodyweight.
Shalom et al. The researchers performed an uncontrolled trial to assess the effects of 12 weeks of aerobic exercise training in 7 patients undergoing hemodialysis. The aerobic exercise training involved cycle ergometer, calisthenics, walking and jogging up to 75 – 80% of maximum heart rate (HR-max) for 45 minutes, 5 times per week. The researchers observed a significant improvement in maximal oxygen consumption during treadmill testing but they did not observe any changes in blood pressure control, hematocrit, or left ventricular ejection fraction.
Moore et al. The researchers performed an uncontrolled trial to assess the effects of 12 weeks of aerobic exercise training in 23 patients undergoing hemodialysis. The aerobic exercise training involved cycle ergometer training at a rating of perceived exertion (RPE) of 6 out of 10 for <60 minutes, 3 times per week. The researchers observed a significant improvement in maximal workload, submaximal heart rate and phosphofructokinase activity but no changes in type I or type II muscle fiber areas or in capillary to muscle fiber ratio.
Załuska et al. The researchers performed an uncontrolled trial to assess the effects of 6 months of aerobic exercise training in 10 patients undergoing hemodialysis. The aerobic exercise training involved cycle ergometer training for 30 minutes, 3 times per week. The researchers observed a significant increase in serum albumin, a decrease in C-reactive protein, an increase in the protein catabolic rate and an improvement in dialysis adequacy.
Mustata et al. The researchers performed an uncontrolled trial to assess the effects of 3 months of aerobic exercise training in 11 patients undergoing hemodialysis. The aerobic exercise training involved treadmill walking or cycle ergometer exercise for 40 – 50 minutes, 2 times per week. The researchers found a significant decrease in arterial stiffness, pulse pressure and systolic blood pressure but no change in insulin resistance.
Zabetakis et al. The researchers performed a non-randomized, controlled trial to assess the effects of 10 weeks of aerobic exercise training in 10 patients undergoing hemodialysis. The aerobic exercise training involved treadmill walking/jogging at anaerobic threshold for 25 – 45 minutes, 3 times per week. The researchers reported significant increases in maximal oxygen consumption, performance in a graded exercise test and anaerobic threshold in the exercise group but no changes in the control group.
Hagberg et al. The researchers performed a non-randomized, controlled trial to assess the effects of 14 ± 5 months of aerobic exercise training in 12 patients undergoing hemodialysis. The aerobic exercise training involved calisthenics, cycle ergometer exercise and walking for <30 minutes at 50 – 85% of VO2-max, 3 – 5 times per week. The researchers reported significant increases in maximal oxygen consumption, performance in a graded exercise test, hemoglobin concentration and hematocrit concentration and a significant decrease in systolic blood pressure in the exercise group but no changes in the control group.
Carney et al. The researchers performed a non-randomized, controlled trial to assess the effects of 6 months of aerobic exercise training in 8 patients undergoing hemodialysis. The aerobic exercise training involved cycle ergometer exercise, walking and jogging at 50 – 60% of VO2-max, 3 times per week. The researchers reported no change in maximal oxygen consumption but a significant increase in performance in a graded exercise test in the exercise group but no changes in the control group. They also reported a significant reduction in anxiety and depression in the exercise group but no changes in the control group.
Painter et al. The researchers performed a non-randomized, controlled trial to assess the effects of 6 months of aerobic exercise training in 20 patients undergoing hemodialysis. The aerobic exercise training involved cycle ergometer exercise at 65 – 85% of VO2-max for 30 – 45 minutes, 3 times per week. The researchers reported a significant increase in maximal oxygen consumption in the exercise group but no changes in the control group.
Miller et al. The researchers performed a non-randomized, controlled trial to assess the effects of 6 months of aerobic exercise training in 75 patients undergoing hemodialysis. The aerobic exercise training involved cycle ergometer exercise to tolerance for around 30 minutes, 3 times per week. The researchers reported that the subjects who completed the full 6 months of exercise displayed a mean increase in cycling time from 16.9 to to 45.5 minutes per session. The researchers observed that 54% of subjects in the exercise group had a reduction in antihypertensive medication while only 12.5% of the subjects in the control group had a reduction in antihypertensive medication.
Moug et al. The researchers performed a non-randomized, controlled trial to assess the effects of 6 weeks of aerobic exercise training in 17 patients undergoing hemodialysis. The aerobic exercise training involved cycle ergometer exercise at 60 – 85% of VO2-max for 45 – 60 minutes, 2 times per week. The researchers observed no changes in leg extension strength or depression but they did observe a redution in anxiety in the exercise group but they did not observe any changes in the control group.
Harter and Goldberg The researchers performed a randomized, controlled trial to assess the effects of 12 months of aerobic exercise training in 25 patients undergoing hemodialysis. The aerobic exercise training involved walking and cycle ergometer exercise at 50 – 80% of VO2-max 45 – 60 minutes, 3 times per week. The researchers observed significant improvements in the exercise group in maximal oxygen consumption, performance in a graded exercise test, plasma triglycerides, very-low-density-lipoprotein (VLDL) triglycerides, VLDL cholesterol, high-density-lipoprotein (HDL), glucose disappearance rate, insulin affinity, hematocrit, red blood cell mass, hemoglobin, basal insulin levels, red blood cell survival, and the score on the Beck depression inventory.
Carney et al. The researchers performed a randomized, controlled trial to assess the effects of 6 months of aerobic exercise training in 21 patients undergoing hemodialysis. The aerobic exercise training involved calisthenics, cycle ergometer exercise and walking at 60 – 80% of VO2-max for 45 – 60 minutes, 3 times per week. The researchers reported that in the exercise group there was a significant reduction in both the score on the Beck depression inventory and in the prevalence of clinical depression.
Akiba et al. The researchers performed a randomized, controlled trial to assess the effects of 12 weeks of aerobic exercise training in 20 patients undergoing hemodialysis. The aerobic exercise training involved cycle ergometer training at a rating of perceived exertion (RPE) of 6 out of 12 for 10 – 20 minutes, 3 times per week. The researchers reported that the exercise group did not change VO2-max or anaerobic threshold but the control group significantly reduced VO2-max and anaerobic threshold.
Kouidi et al. The researchers performed a randomized, controlled trial to assess the effects of 6 months of aerobic exercise training in 31 patients undergoing hemodialysis. The aerobic exercise training involved cycle ergometer exercise, walking/jogging, calisthenics, aerobics, swimming and ball games at 50 – 70% of VO2-max for 90 minutes, 3 – 4 times per week. The researchers reported that the exercise group significantly improved maximal oxygen consumption and performance in a graded exercise test, as well as score in the Beck depression inventory and various measures of quality of life.
Frey et al. The researchers performed a randomized, controlled trial to assess the effects of 7 weeks of aerobic exercise training in 11 patients undergoing hemodialysis. The aerobic exercise training involved cycle ergometer training for <45 minutes at 60 – 80% of maximum heart rate (HR-max), 3 times per week. The researchers did not identify any statistically significant differences between groups as a result of the intervention in respect of serum levels of prealbumin, transferrin, and predialysis and postdialysis albumin, which would indicate differences in dialysis adequacy. However, they did observe that a majority of the patients in the exercise group expressed feelings of improved health, better exercise tolerance, improved appetite and viewed exercise as enjoyable.
Painter et al. The researchers performed a randomized, controlled trial to assess the effects of 5 months of aerobic exercise training in comparison with the same period of aerobic training combined with erythropoietin in 48 patients undergoing hemodialysis. The aerobic exercise training involved cycle ergometer training at a rating of perceived exertion (RPE) of 12 – 14 for 30 minutes, 3 times per week. The researchers reported that both exercise groups significantly improved maximal oxygen consumption and score in the Short Form-36 questionnaire (SF-36) physical functioning subscale.
Molsted et al. The researchers performed a randomized, controlled trial to assess the effects of 5 months of aerobic exercise training in 33 patients undergoing hemodialysis. The aerobic exercise training involved step exercises, cycling and aerobics at a rating of perceived exertion (RPE) of 14 – 17 for 60 minutes, 2 times per week. The researchers reported that the exercise group significantly improved maximal oxygen consumption and score in the Short Form-36 questionnaire (SF-36) physical functioning, bodily pain and physical component subscales.
Parsons et al. The researchers performed a randomized, controlled trial to assess the effects of 8 weeks of aerobic exercise training in 13 patients undergoing hemodialysis. The aerobic exercise training involved cycle ergometer training at 40 – 50% of VO2-max for 45 minutes, 3 times per week. The researchers observed a significant change in dialysate urea clearance but no changes in maximal work capacity, blood urea clearance or quality of life in the exercise group.
Moinuddin and Leehey The researchers performed a narrative review of the literature in respect of the use of aerobic exercise in the treatment of chronic kidney disease. They reported that in non-dialysis chronic kidney disease patients, aerobic exercise decreases micro-albuminuria, protects from oxidative stress and may increase the glomerular filtration rate. They reported that aerobic exercise in haemodialysis chronic kidney disease patients improves measures of insulin sensitivity, lipid profile, haemoglobin, muscular strength, blood pressure and quality of life.
Cheema and Singh The researchers performed a systematic review of clinical trials of exercise training in patients receiving maintenance hemodialysis. The vast majority of patients diagnosed with end-stage renal disease receive maintenance hemodialysis treatment as renal replacement therapy. The review included all trials that involved either aerobic and/or resistance training modalities >5 weeks in duration. The reviewers concluded that the evidence suggests that appropriately prescribed exercise involving aerobic and/or resistance training modalities is both safe and beneficial for hemodialysis patients.

Based on these studies and reviews, aerobic exercise is certainly beneficial for improving  blood pressure, muscular strength, aerobic capacity, physical function and quality of life in patients with chronic kidney disease. It may also be beneficial for reducing symptoms and for improving glomerular filtration rate.

Is resistance-training useful for chronic kidney disease?

A small number of studies have investigated the use of resistance training interventions for the treatment of chronic kidney disease, as follows:

Study Description Finding
Headley et al. The researchers performed an uncontrolled trial to assess the effects of 12 weeks of resistance training in 10 patients undergoing hemodialysis. The resistance training involved 8 – 9 machine weight exercises for 1 – 2 sets of 15 reps, twice per week and home- based elastic band exercises using a Theraband once per week. The researchers observed significant increases in peak isometric force at 90 degrees, 6-minute walk distance, maximal walking speed, sit-to-stand time for 10 reps and body fat percentage.
Johansen et al. The researchers performed a randomized controlled trial to assess the independent effects of both anabolic steroids and resistance training over a 12-week period in 79 patients undergoing maintenance hemodialysis. The researchers randomly allocated the subjects to either weekly injecctions of nandrolone decanoate or placebo injections and lower body resistance exercise training, 3 times per week using ankle weights. The researchers did not observe a significant increase in lean body mass as a result of exercise but they did observe significant increases in quadriceps muscle cross-sectional area, muscular strength and self-reported physical function.
Cheema et al. The researchers assessed the effects of 12 weeks of high-intensity, progressive resistance training during in 49 patients undergoing routine hemodialysis treatment on muscle mass. The researchers randomly allocated the subjects to either a resistance training group or to a control group who received usual care. The resistance training involved 2 sets of 10 exercises at a high-intensity (15 – 17 out of 20 on the Borg Scale) using free weights, 3 times per week. The researchers did not identify any statistically significant increases in muscle cross-sectional area of the thigh but they did observe statistically significant improvements in muscle attenuation, muscle strength, mid-thigh and mid-arm circumference, bodyweight and C-reactive protein, indicating that skeletal muscle quality can be improved through resistance training.
Castaneda et al. The researchers assessed the effects of resistance training in 26 adults with chronic kidney disease but who were not on dialysis therapy. The researchers randomly allocated the subjects to either a resistance training group or to a control group for a 12-week intervention. All subjects were counseled to consume a low-protein diet of 0.6g/kg per day. The researchers found that serum C-reactive protein levels and IL-6 levels were reduced in the resistance-exercise group compared with the control group. The researchers also found that muscular hypertrophy of both type I (24% ± 31%) and type II (22% ± 41%) muscle fiber cross-sectional areas occurred compared in the resistance training group but atrophy of both type I and type Ii fibers occurred in the control group (-14% ± 34% and -13% ± 18%, respectively). The researchers also reported that muscular strength also in the resistance training group but decreased in the control group (28% ± 14% vs. -13% ± 22%).
Castaneda et al. The researchers performed a randomized, controlled trial to assess the efficacy of resistance training in preventing the loss of muscle mass that occurred in patients with chronic renal insufficiency who were being counseled to consume a low-protein diet of 0.6g/kg per day. The researchers found that total body potassium and type I and II muscle-fiber cross-sectional areas increased significantly in the resistance training group in comparison with the control group. Additionally, the resistance training group maintained bodyweight but the control group did not. The resistance training group increased muscle strength (32% ± 14%) while the control group lost muscular strength (-13% ± 20%). The researchers concluded that resistance training is therefore effective at preventing the catabolism that occurs as a result of a low-protein diet in patients with renal failure.
Balakrishnan et al. The researchers performed a a secondary analysis from a randomized controlled trial in order to assess the effects of resistance training on skeletal muscle mitochondrial (mt)DNA copy number and its association with skeletal muscle mass and strength in 23 patients with moderate-to-severe chronic kidney disease. The researchers randomly allocated the subjects to either a resistance training or an attention-control group for a 12-week intervention. All subjects were consuming a low-protein diet of 0.6g/kg per day.  The resistance training group exercised 3 times per week under supervision for 45 minutes per session and performed on chest and leg press, latissimus pull-down, knee extension and knee flexion pneumatic resistance training machine exercises for 3 sets of 8 repetitions at 80% of 1RM in addition to 5 – 8 upper and lower body-stretches. The researchers found that the resistance training group displayed improved protein utilization, muscular hypertrophy and increased muscle strength. They also reported that skeletal muscle mitochondrial median mtDNA copy number increased significantly compared with that of the control group in which there was a significant reduction.
Segura-Ortí et al. The researchers performed a non-randomized, controlled trial to assess the effects of resistance training in 16 patients with end-stage renal disease receiving hemodialysis. The resistance training group performed an intradialytic exercise program supervised by a physiotherapist that involved both isometric and isotonic exercises for the lower body while the control group peformed no exercises. The researchers reported that the resistance training group significantly increased distance in the 6-minute walk test after the intervention (399.57 ± 39.56 vs. 471.71 ± 70.6m) and significantly improved performance in two sit-to-stand tests. The researchers also found that the score on the mental subscale of the Short Form-36 questionnaire (SF-36) significantly increased in the resistance training group and significantly decreased in the control group.
Moinuddin and Leehey The reviewers performed a narrative review of the literature in respect of the use of resistance-training in the treatment of chronic kidney disease. The researchers reported that, in non-dialysis chronic kidney disease patients, resistance training improves measures of inflammation, serum albumin, bodyweight maintenance, muscular strength, IGF-1 status and glomerular filtration rate. The researchers reported that in hemodialysis chronic kidney disease patients, resistance training improves measures of muscle strength, physical function and IGF-1 status.
Cheema and Singh The reviewers performed a systematic review of clinical trials of exercise training in patients receiving maintenance hemodialysis. The vast majority of patients diagnosed with end-stage renal disease receive maintenance hemodialysis treatment as renal replacement therapy. The review included all trials that involved either aerobic and/or resistance training modalities >5 weeks in duration. The reviewers concluded that the evidence suggests that appropriately prescribed exercise involving aerobic and/or resistance training modalities is both safe and beneficial for hemodialysis patients.

Based on these studies and reviews, resistance training is certainly effective for improving muscular strength and physical function and for increasing muscle mass in the face of a catabolic, low-protein diet in patients with chronic kidney disease who would otherwise suffer marked muscular atrophy.

Is concurrent training useful for chronic kidney disease?

A number of studies have investigated the use of concurrent training interventions (combined aerobic exercise and resistance-training) for the treatment of chronic kidney disease, as follows:

Study Description Finding
Ridley et al. The researchers performed an uncontrolled trial to assess the effects of 12 weeks of concurrent exercise training in 8 patients undergoing hemodialysis. The concurrent training involved cycle ergometer exercise for <30 minutes to tolerance and 6 strength exercises for <30 reps, 2 times per week. The researchers observed significant increases in 6-minute walk distance and resistance training load and significant decreases in affective fatigue and sensory scale fatigue measures on the Piper fatigue scale.
Oh-Park et al. The researchers performed an uncontrolled trial to assess the effects of 3 months of concurrent exercise training in 22 patients undergoing hemodialysis. The concurrent training involved cycle ergometer exercise for <30 minutes to tolerance and knee extension resistance exercise for 3 sets of 15 reps at 50% of 1RM, 2 – 3 times per week. The researchers observed significant improvements in knee extension strength and in Short Form-36 questionnaire (SF-36) physical functioning and mental health subscale scores.
Kouidi et al. The researchers performed an uncontrolled trial to assess the effects of 6 months of concurrent exercise training in 7 patients undergoing hemodialysis. The concurrent training involved aerobic and strength training for 90 minutes, 3 times per week. The researchers observed significant increases in maximal oxygen consumption, performance in a graded exercise test, peak blood lactate, nerve conduction velocity, isometric strength, type I, II and total muscle fiber area and percentage of type II fibers.
Painter et al. The researchers performed a non-randomized, controlled trial to assess the effects of 16 weeks of concurrent exercise training in 286 patients undergoing hemodialysis. The concurrent training involved walking and cycle ergometer exercise to tolerance in addition to strength training. The researchers observed significant increases in habitual gait speed, fastest gait speed, sit-to-stand speed and 6-minute walk distance in addition to scores on the Short Form-36 questionnaire (SF-36) physical functioning, role physical, general health, bodily pain and physical component subscales.
Deligiannis et al. The researchers performed a randomized, controlled trial to assess the effects of 6 months of concurrent exercise training in 60 patients undergoing hemodialysis. The concurrent training involved calisthenics, aerobics, swimming or ball games and strength exercises. The endurance component of the exercise was performed at 50 – 70% of VO2-max and the total amount of exercise was performed for 90 minutes 3 – 4 times per week. The researchers found that maximal oxygen consumption, performance in a graded exercise test and heart rate variability (HRV) index all improved significantly in the exercise group.
Deligiannis et al. The researchers performed a randomized, controlled trial to assess the effects of 6 months of concurrent exercise training in 38 patients undergoing hemodialysis. The concurrent training involved calisthenics and steps for <70 minutes and strength exercises 3 times per week. The researchers observed that the concurrent group displayed significant improvements in left ventricle mass index, ejection fraction, stroke volume index and cardiac output index.
DePaul et al. The researchers performed a randomized, controlled trial to assess the effects of 12 weeks of concurrent exercise training in 37 patients undergoing hemodialysis. The concurrent training involved cycle ergomter exercise at a rating of perceived exertion (RPE) on the Borg scale of 13 out of 20 or <80% of heart rate maximum (HR-max) for 20 minutes in addition to strength exercise involving knee extensions for 3 sets of 10 repetitions at 50% of 5RM, 3 times per week. The control group performed a non-progressive program of range-of-motion exercises. The researchers reported that the subjects in the concurrent training group displayed significant improvements in submaximal exercise capacity and knee extension strength but not in the but not in 6-minute walk test distance, symptoms questionnaire or Short Form-36 questionnaire (SF-36).
Konstantinidou et al. The researchers performed a randomized, controlled trial to assess the effects of 6 months of concurrent exercise training in 48 patients undergoing hemodialysis. The concurrent training involved aerobic training at 50 – 70% of VO2-max for 60 minutes and strength exercises 3 times per week. The researchers found that the concurrent training group maximal oxygen consumption, performance in a graded exercise test and anaerobic threshold.
Kouidi et al. The researchers performed a randomized, controlled trial to assess the effects of 4 years of concurrent exercise training in 34 patients undergoing hemodialysis. The concurrent training involved aerobic training at 50 – 70% of VO2-max for 60 minutes and strength exercises 3 times per week. The researchers found that the concurrent training group maximal oxygen consumption, performance in a graded exercise test and anaerobic threshold.
Moinuddin and Leehey The reviewers performed a narrative review of the literature in respect of the use of concurrent training (combined aerobic and resistance-training) during dialysis. The reviewers reported that concurrent training improves measures of muscular strength, work output, cardiovascular fitness and possibly dialysis adequacy.

Based on these studies and reviews, concurrent exercise is certainly beneficial for improving  blood pressure, muscular strength and mass, aerobic capacity, physical function and quality of life in patients with chronic kidney disease. It may also be beneficial for reducing symptoms and for improving glomerular filtration rate.


What is the economic burden of chronic kidney disease?

A small number of studies have either reviewed the economic burden of chronic kidney disease or have assessed the economic validity of exercise treatments in relation to renal disease, as follows:

Study Finding
Lysaght The researcher estimated the global maintenance dialysis population at around 1.1 million patients in 2001, noting that the rate of increase was 7% per annum and that the figure would likely reach 2.0 million by 2010. The researcher observed that since the average therapy cost per patient per year in the United States was around $66,000, this provides an estimate of the worldwide cost of maintenance end-stage renal disease therapy of $70 – 75 billion per annum.
Grassmann et al. The researchers estimated that at the end of 2004, 1.783 million people worldwide were undergoing treatment for end-stage renal disease, which included 1.371 million who were on dialysis treatment. The researchers observed that the growth rate of treated end-stage renal disease patients from 2003 – 2004 was between 6 – 7%. The researchers suggested that extrapolating the 2004 patient numbers using the 2003 – 2004 growth rates indicates that 2 million people will be on dialysis by 2010.
Lee et al. The researchers carried out a prospective trial in which they followed 166 patients for 1 year who had been on dialysis therapy already for >6 months in order to assess the costs involved. The researchers reported that the annual cost of care for in-center, satellite, and home/self-care hemodialysis and peritoneal dialysis were $51,252, $42,057, $29,961 and $26,959, respectively.
Goeree et al. The researchers evaluated the various costs of different dialysis modalities for the treatment of end-stage renal disease in a regional nephrology program in south-western Ontario, Canada. The researchers reported that the costs in 1993 Canadian dollars (US$1.00 is very approximately = CAN$1.00) for hospital hemodialysis, self-care hemodialysis, continuous ambulatory peritoneal dialysis and home hemodialysis per patient per year were $88,585, $55,593, $44,790 and $32,570, respectively.
Dirks et al. The reviewers explained that around 50 million people suffer from progressive chronic kidney disease in the world, of which 85% live in industrialized countries. The reviewers observe that the incidence of end-stage renal disease has doubled over 15 years and is predicted to double again over the next 10 years, largely as a result of increasing incidence of type 2 diabetes and obesity. Indeed, the reviewers observe that intrinsic renal disease is actually currently in decline but the rise in non-communicable diseases is leading to significant increases in secondary damage to the kidney. They note that between 30 – 50% of all current cases of end-stage renal disease in industrialized countries are caused by either diabetes or hypertension. The reviewers note that other researchers have estimated the annual cost of renal replacement therapy in the United States as US$22.8 billion and predict that it will increase above US$30 billion over the next 10 years.

Based on these studies, the worldwide prevalence of chronic kidney disease appears to be around 50 million people, although only around 2 million currently require renal replacement therapy. At an estimated cost of around $50,000 per person per year, the worldwide per annum cost of dialysis is probably around US$100 billion at present.


Conclusions

On the basis of these studies and reviews, the following conclusions might be drawn:

Area Conclusion
Exercise is useful in chronic kidney disease In general aerobic exercise, resistance training and concurrent training (combined aerobic and resistance training) have all been shown to be beneficial in patients with chronic kidney disease, including those undergoing renal replacement therapy.
Aerobic exercise improves key vascular health markers In general, aerobic exercise seems primarily beneficial for improving  blood pressure and aerobic capacity, as well as physical function and quality of life in patients with chronic kidney disease. It may also be beneficial for reducing symptoms and for improving glomerular filtration rate.
Resistance training reduces loss of muscle mass In general, resistance training is effective for increasing or reducing the loss muscle mass in the face of a catabolic, low-protein diet in patients with chronic kidney disease who would otherwise suffer marked muscular atrophy.

Based on these studies, properly programmed aerobic exercise, resistance training and concurrent training all have applications in the treatment of chronic kidney disease and may therefore be a useful adjunct to current treatment methods.


References

  1. Levey, A. S., de Jong, P. E., Coresh, J., El Nahas, M., Astor, B. C., Matsushita, K., & Eckardt, K. U. (2010). The definition, classification, and prognosis of chronic kidney disease: a KDIGO Controversies Conference report. Kidney international, 80(1), 17-28.
  2. Coresh, J., & Stevens, L. A. (2006). Kidney function estimating equations: where do we stand?. Current opinion in nephrology and hypertension, 15(3), 276-284.
  3. Lin, J., Knight, E. L., Hogan, M. L., & Singh, A. K. (2003). A comparison of prediction equations for estimating glomerular filtration rate in adults without kidney disease. Journal of the American Society of Nephrology, 14(10), 2573-2580.
  4. Lamb, E. J., Tomson, C. R., & Roderick, P. J. (2005). Estimating kidney function in adults using formulae. Annals of clinical biochemistry, 42(5), 321-345.
  5. Levey, A. S., Coresh, J., Greene, T., Stevens, L. A., Zhang, Y. L., Hendriksen, S., & Van Lente, F. (2006). Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Annals of internal medicine, 145(4), 247-254.
  6. Amato, D., Alvarez-Aguilar, C., Castañeda-Limones, R., Rodriguez, E., Avila-Diaz, M., Arreola, F., & Paniagua, R. (2005). Prevalence of chronic kidney disease in an urban Mexican population. Kidney international. Supplement, (97), S11.
  7. Brown, W. W., Peters, R. M., Ohmit, S. E., Keane, W. F., Collins, A., Chen, S. C., & Flack, J. M. (2003). Early detection of kidney disease in community settings: the Kidney Early Evaluation Program (KEEP). American journal of kidney diseases, 42(1), 22-35
  8. Cirillo, M., Laurenzi, M., Mancini, M., Zanchetti, A., Lombardi, C., & De Santo, N. G. (2006). Low glomerular filtration in the population: prevalence, associated disorders, and awareness. Kidney international, 70(4), 800-806.
  9. Coresh, J., Astor, B. C., Greene, T., Eknoyan, G., & Levey, A. S. (2003). Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination Survey. American Journal of Kidney Diseases, 41(1), 1-12.
  10. Coresh, J., Byrd-Holt, D., Astor, B. C., Briggs, J. P., Eggers, P. W., Lacher, D. A., & Hostetter, T. H. (2005). Chronic kidney disease awareness, prevalence, and trends among US adults, 1999 to 2000. Journal of the American Society of Nephrology, 16(1), 180-188.
  11. Fox, C. S., Larson, M. G., Vasan, R. S., Guo, C. Y., Parise, H., Levy, D., & Benjamin, E. J. (2006). Cross-sectional association of kidney function with valvular and annular calcification: the Framingham heart study. Journal of the American Society of Nephrology, 17(2), 521-527.
  12. Garg, A. X., Papaioannou, A., Ferko, N., Campbell, G., Clarke, J. A., & Ray, J. G. (2004). Estimating the prevalence of renal insufficiency in seniors requiring long-term care. Kidney international, 65(2), 649.
  13. Hallan, S. I., Coresh, J., Astor, B. C., Åsberg, A., Powe, N. R., Romundstad, S., & Holmen, J. (2006). International comparison of the relationship of chronic kidney disease prevalence and ESRD risk. Journal of the American Society of Nephrology, 17(8), 2275-2284.
  14. Hemmelgarn, B. R., Zhang, J., Manns, B. J., Tonelli, M., Larsen, E., Ghali, W. A., & Culleton, B. F. (2006). Progression of kidney dysfunction in the community-dwelling elderly. Kidney international, 69(12), 2155-2161.
  15. Kramer, H., Toto, R., Peshock, R., Cooper, R., & Victor, R. (2005). Association between chronic kidney disease and coronary artery calcification: the Dallas Heart Study. Journal of the American Society of Nephrology, 16(2), 507-513.
  16. Manjunath, G., Tighiouart, H., Coresh, J., Macleod, B., Salem, D. N., Griffith, J. L., & Sarnak, M. J. (2003). Level of kidney function as a risk factor for cardiovascular outcomes in the elderly. Kidney international, 63(3), 1121-1129.
  17. McClellan, W., Warnock, D. G., McClure, L., Campbell, R. C., Newsome, B. B., Howard, V., & Howard, G. (2006). Racial differences in the prevalence of chronic kidney disease among participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Cohort Study. Journal of the American Society of Nephrology, 17(6), 1710-1715.
  18. Nitsch, D., Dietrich, D. F., von Eckardstein, A., Gaspoz, J. M., Downs, S. H., Leuenberger, P., & Ackermann-Liebrich, U. (2006). Prevalence of renal impairment and its association with cardiovascular risk factors in a general population: results of the Swiss SAPALDIA study. Nephrology Dialysis Transplantation, 21(4), 935-944.
  19. Otero, A., Gayoso, P., Garcia, F., & DE FRANCISCO, Á. L. (2005). Epidemiology of chronic renal disease in the Galician population: results of the pilot Spanish EPIRCE study. Kidney International, 68, S16-S19.
  20. Wasen, E., Isoaho, R., Mattila, K., Vahlberg, T., Kivelä, S. L., & Irjala, K. (2004). Estimation of glomerular filtration rate in the elderly: a comparison of creatinine‐based formulae with serum cystatin C. Journal of internal medicine, 256(1), 70-78.
  21. Haroun, M. K., Jaar, B. G., Hoffman, S. C., Comstock, G. W., Klag, M. J., & Coresh, J. (2003). Risk factors for chronic kidney disease: a prospective study of 23,534 men and women in Washington County, Maryland. Journal of the American Society of Nephrology, 14(11), 2934-2941.
  22. Perneger, T. V., Brancati, F. L., Whelton, P. K., & Klag, M. J. (1994). End-stage renal disease attributable to diabetes mellitus. Annals of internal medicine, 121(12), 912-918.
  23. Brancati, F. L., Whelton, P. K., Randall, B. L., Neaton, J. D., Stamler, J., & Klag, M. J. (1997). Risk of End-stage Renal Disease in Diabetes Mellitus: A Prospective Cohort Study of Men Screened for MRFIT. JAMA: The Journal of the American Medical Association, 278(23), 2069-2074.
  24. Chen, J., Muntner, P., Hamm, L. L., Jones, D. W., Batuman, V., Fonseca, V., & He, J. (2004). The metabolic syndrome and chronic kidney disease in US adults. Annals of internal medicine, 140(3), 167.
  25. Klag, M. J., Whelton, P. K., Randall, B. L., Neaton, J. D., Brancati, F. L., Ford, C. E., & Stamler, J. (1996). Blood pressure and end-stage renal disease in men. New England Journal of Medicine, 334(1), 13-18.
  26. Iseki, K., Ikemiya, Y., & Fukiyama, K. (1996). Blood pressure and risk of end-stage renal disease in a screened cohort. Kidney international. Supplement, 55, S69.
  27. Gambaro, G., Verlato, F., Budakovic, A., Casara, D., Saladini, G., Del Prete, D.,  & Baggio, B. (1998). Renal impairment in chronic cigarette smokers. Journal of the American Society of Nephrology, 9(4), 562-567.
  28. Hsu, C. Y., McCulloch, C. E., Iribarren, C., Darbinian, J., & Go, A. S. (2006). Body mass index and risk for end-stage renal disease. Annals of internal medicine, 144(1), 21.
  29. Hsu, C. Y., McCulloch, C. E., Darbinian, J., Go, A. S., & Iribarren, C. (2005). Elevated blood pressure and risk of end-stage renal disease in subjects without baseline kidney disease. Archives of internal medicine, 165(8), 923.
  30. Hsu, C. Y., Iribarren, C., McCulloch, C. E., Darbinian, J., & Go, A. S. (2009). Risk Factors for End-Stage Renal Disease: 25-Year Follow-up. Archives of internal medicine, 169(4), 342.
  31. Tozawa, M., Iseki, K., Iseki, C., Kinjo, K., Ikemiya, Y., & Takishita, S. (2003). Blood pressure predicts risk of developing end-stage renal disease in men and women. Hypertension, 41(6), 1341-1345.
  32. Reynolds, K., Gu, D., Muntner, P., Kusek, J. W., Chen, J., Wu, X., & He, J. (2007). A population-based, prospective study of blood pressure and risk for end-stage renal disease in China. Journal of the American Society of Nephrology: JASN, 18(6), 1928.
  33. Robinson-Cohen, C., Katz, R., Mozaffarian, D., Dalrymple, L. S., de Boer, I., Sarnak, M., & Kestenbaum, B. (2009). Physical activity and rapid decline in kidney function among older adults. Archives of internal medicine, 169(22), 2116.
  34. Hawkins, M. S., Sevick, M. A., Richardson, C. R., Fried, L. F., Arena, V. C., & Kriska, A. M. (2011). Association between physical activity and kidney function: National Health and Nutrition Examination Survey. Med Sci Sports Exerc, 43(8), 1457-64.
  35. White, S. L., Dunstan, D. W., Polkinghorne, K. R., Atkins, R. C., Cass, A., & Chadban, S. J. (2011). Physical inactivity and chronic kidney disease in Australian adults: The AusDiab study. Nutrition, Metabolism and Cardiovascular Diseases, 21(2), 104-112.
  36. Lynch, B. M., White, S. L., Owen, N., Healy, G. N., Chadban, S. J., Atkins, R. C., & Dunstan, D. W. (2010). Television viewing time and risk of chronic kidney disease in adults: The AusDiab study. Annals of Behavioral Medicine, 40(3), 265-274.
  37. Boyce, M. L., Robergs, R. A., Avasthi, P. S., Roldan, C., Foster, A., Montner, P., & Nelson, C. (1997). Exercise training by individuals with predialysis renal failure: cardiorespiratory endurance, hypertension, and renal function. American journal of kidney diseases, 30(2), 180-192.
  38. Clyne, N., Ekholm, J., Jogestrand, T., Lins, L. E., & Pehrsson, S. K. (1991). Effects of exercise training in predialytic uremic patients. Nephron, 59(1), 84-89.
  39. Eidemak, I., BirgitteHaaber, A., Feldt-Rasmussen, B., Kanstrup, I. L., & Strandgaard, S. (1997). Exercise training and the progression of chronic renal failure. Nephron, 75(1), 36-40.
  40. Fitts, S. S., Guthrie, M. R., & Blagg, C. R. (1999). Exercise coaching and rehabilitation counseling improve quality of life for predialysis and dialysis patients. Nephron, 82(2), 115.
  41. Heiwe, S., Tollbäck, A., & Clyne, N. (2001). Twelve Weeks of Exercise TrainingIncreases Muscle Function and Walking Capacity in Elderly Predialysis Patients and Healthy Subjects. Nephron, 88(1), 48-56.
  42. Kosmadakis, G. C., John, S. G., Clapp, E. L., Viana, J. L., Smith, A. C., Bishop, N. C., & Feehally, J. (2012). Benefits of regular walking exercise in advanced pre-dialysis chronic kidney disease. Nephrology Dialysis Transplantation, 27(3), 997-1004.
  43. Pechter, Ü., Ots, M., Mesikepp, S., Zilmer, K., Kullissaar, T., Vihalemm, T., & Maaroos, J. (2003). Beneficial effects of water-based exercise in patients with chronic kidney disease. International Journal of Rehabilitation Research, 26(2), 153-156.
  44. Goldberg, A. P., Hagberg, J. M., Delmez, J. A., Haynes, M. E., & Harter, H. R. (1980). Metabolic effects of exercise training in hemodialysis patients. Kidney Int, 18(6), 754-61.
  45. Shalom, R., Blumenthal, J. A., Williams, R. S., McMurray, R. G., & Dennis, V. W. (1984). Feasibility and benefits of exercise training in patients on maintenance dialysis. Kidney international, 25(6), 958-963.
  46. Moore, G. E., Parsons, D. B., Stray-Gundersen, J., Painter, P. L., Brinker, K. R., & Mitchell, J. H. (1993). Uremic myopathy limits aerobic capacity in hemodialysis patients. American journal of kidney diseases, 22(2), 277-287.
  47. Załuska, A., Załuska, W. T., Bednarek-Skublewska, A., & Ksiazek, A. (2001). Nutrition and hydration status improve with exercise training using stationary cycling during hemodialysis (HD) in patients with end-stage renal disease (ESRD). In Annales Universitatis Mariae Curie-Sklodowska. Sectio D: Medicina (Vol. 57, No. 2, pp. 342-346).
  48. Mustata, S., Chan, C., Lai, V., & Miller, J. A. (2004). Impact of an exercise program on arterial stiffness and insulin resistance in hemodialysis patients. Journal of the American Society of Nephrology, 15(10), 2713-2718.
  49. Zabetakis, P. M., Gleim, G. W., Pasternack, F. L., Saraniti, A., Nicholas, J. A., & Michelis, M. F. (1982). Long-duration submaximal exercise conditioning in hemodialysis patients. Clinical nephrology, 18(1), 17-22.
  50. Hagberg, J. M., Goldberg, A. P., Ehsani, A. A., Heath, G. W., Delmez, J. A., & Harter, H. R. (1983). Exercise training improves hypertension in hemodialysis patients. American journal of nephrology, 3(4), 209-212.
  51. Carney, R. M., McKevitt, P. M., Goldberg, A. P., Hagberg, J., Delmez, J. A., & Harter, H. R. (1983). Psychological effects of exercise training in hemodialysis patients. Nephron, 33(3), 179-181.
  52. Painter, P. L., Nelson-Worel, J. N., Hill, M. M., Thornbery, D. R., Shelp, W. R., Harrington, A. R., & Weinstein, A. B. (1986). Effects of exercise training during hemodialysis. Nephron, 43(2), 87.
  53. Miller, B. W., Cress, C. L., Johnson, M. E., Nichols, D. H., & Schnitzler, M. A. (2002). Exercise during hemodialysis decreases the use of antihypertensive medications. American journal of kidney diseases: the official journal of the National Kidney Foundation, 39(4), 828.
  54. Moug, S. J., Grant, S., Creed, G., & Boulton, J. M. (2004). Exercise during haemodialysis: West of Scotland pilot study. Scottish medical journal, 49(1), 14.
  55. Harter, H. R., & Goldberg, A. P. (1985). Endurance exercise training. An effective therapeutic modality for hemodialysis patients. The Medical clinics of North America, 69(1), 159.
  56. Carney, R. M., Templeton, B., Hong, B. A., Harter, H. R., Hagberg, J. M., Schechtman, K. B., & Goldberg, A. P. (1987). Exercise training reduces depression and increases the performance of pleasant activities in hemodialysis patients. Nephron, 47(3), 194.
  57. Akiba, T., Matsui, N., Shinohara, S., Fujiwara, H., Nomura, T., & Marumo, F. (1995). Effects of recombinant human erythropoietin and exercise training on exercise capacity in hemodialysis patients. Artificial organs, 19(12), 1262.
  58. Kouidi, E., Iacovides, A., Iordanidis, P., Vassiliou, S., Deligiannis, A., Ierodiakonou, C., & Tourkantonis, A. (1997). Exercise renal rehabilitation program: psychosocial effects. Nephron, 77(2), 152.
  59. Frey, S., Mir, A. R., & Lucas, M. (1999). Visceral protein status and caloric intake in exercising versus nonexercising individuals with end-stage renal disease. Journal of renal nutrition: the official journal of the Council on Renal Nutrition of the National Kidney Foundation, 9(2), 71.
  60. Painter, P., Moore, G., Carlson, L., Paul, S., Myll, J., Phillips, W., & Haskell, W. (2002). Effects of exercise training plus normalization of hematocrit on exercise capacity and health-related quality of life. American journal of kidney diseases: the official journal of the National Kidney Foundation, 39(2), 257.
  61. Molsted, S., Eidemak, I., Sorensen, H. T., & Kristensen, J. H. (2004). Five months of physical exercise in hemodialysis patients: effects on aerobic capacity, physical function and self-rated health. Nephron. Clinical practice, 96(3), c76.
  62. Parsons, T. L., Toffelmire, E. B., & King-VanVlack, C. E. (2004). The effect of an exercise program during hemodialysis on dialysis efficacy, blood pressure and quality of life in end-stage renal disease (ESRD) patients. Clinical nephrology, 61(4), 261.
  63. Moinuddin, I., & Leehey, D. J. (2008). A comparison of aerobic exercise and resistance training in patients with and without chronic kidney disease. Advances in chronic kidney disease, 15(1), 83-96.
  64. Cheema, B. S. B., & Singh, F. (2005). Exercise training in patients receiving maintenance hemodialysis: a systematic review of clinical trials. American journal of nephrology, 25(4), 352-364.
  65. Headley, S., Germain, M., Mailloux, P., Mulhern, J., Ashworth, B., Burris, J., & Jones, M. (2002). Resistance training improves strength and functional measures in patients with end-stage renal disease. American journal of kidney diseases, 40(2), 355-364.
  66. Johansen, K. L., Painter, P. L., Sakkas, G. K., Gordon, P., Doyle, J., & Shubert, T. (2006). Effects of resistance exercise training and nandrolone decanoate on body composition and muscle function among patients who receive hemodialysis: a randomized, controlled trial. Journal of the American Society of Nephrology, 17(8), 2307-2314.
  67. Cheema, B., Abas, H., Smith, B., O’Sullivan, A., Chan, M., Patwardhan, A., & Singh, M. F. (2007). Progressive exercise for anabolism in kidney disease (PEAK): a randomized, controlled trial of resistance training during hemodialysis. Journal of the American Society of Nephrology: JASN, 18(5), 1594.
  68. Castaneda, C., Gordon, P. L., Parker, R. C., Uhlin, K. L., Roubenoff, R., & Levey, A. S. (2004). Resistance training to reduce the malnutrition-inflammation complex syndrome of chronic kidney disease. American journal of kidney diseases: the official journal of the National Kidney Foundation, 43(4), 607.
  69. Castaneda, C., Gordon, P. L., Uhlin, K. L., Levey, A. S., Kehayias, J. J., Dwyer, J. T., & Singh, M. F. (2001). Resistance Training To Counteract the Catabolism of a Low-Protein Diet in Patients with Chronic Renal Insufficiency. Ann Intern Med, 135, 965-976.
  70. Balakrishnan, V. S., Rao, M., Menon, V., Gordon, P. L., Pilichowska, M., Castaneda, F., & Castaneda-Sceppa, C. (2010). Resistance Training Increases Muscle Mitochondrial Biogenesis in Patients with Chronic Kidney Disease. Clinical Journal of the American Society of Nephrology: CJASN, 5(6), 996.
  71. Segura-Ortí, E., Rodilla-Alama, V., & Lisón, J. F. (2008). [Physiotherapy during hemodialysis: results of a progressive resistance-training programme]. Nefrología: publicación oficial de la Sociedad Española Nefrologia, 28(1), 67.
  72. Ridley, J., Hoey, K., & Ballagh-Howes, N. (1999). The exercise-during-hemodialysis program: report on a pilot study. CANNT journal= Journal ACITN, 9(3), 20.
  73. Oh-Park, M., Fast, A., Gopal, S., Lynn, R., Frei, G., Drenth, R., & Zohman, L. (2002). Exercise for the dialyzed: aerobic and strength training during hemodialysis. American journal of physical medicine & rehabilitation, 81(11), 814-821.
  74. Kouidi, E., Albani, M., Natsis, K., Megalopoulos, A., Gigis, P., Guiba-Tziampiri, O., & Deligiannis, A. (1998). The effects of exercise training on muscle atrophy in haemodialysis patients. Nephrology Dialysis Transplantation, 13(3), 685-699.
  75. Painter, P., Carlson, L., Carey, S., Paul, S. M., & Myll, J. (2000). Low-functioning hemodialysis patients improve with exercise training. American journal of kidney diseases, 36(3), 600-608.
  76. Deligiannis, A., Kouidi, E., & Tourkantonis, A. (1999). Effects of physical training on heart rate variability in patients on hemodialysis. The American journal of cardiology, 84(2), 197-202.
  77. Deligiannis, A., Kouidi, E., Tassoulas, E., Gigis, P., Tourkantonis, A., & Coats, A. (1999). Cardiac effects of exercise rehabilitation in hemodialysis patients. International journal of cardiology, 70(3), 253-266.
  78. DePaul, V., Moreland, J., Eager, T., & Clase, C. M. (2002). The effectiveness of aerobic and muscle strength training in patients receiving hemodialysis and EPO: a randomized controlled trial. American journal of kidney diseases, 40(6), 1219-1229.
  79. Konstantinidou, E., Koukouvou, G., Kouidi, E., Deligiannis, A., & Tourkantonis, A. (2002). Exercise training in patients with end-stage renal disease on hemodialysis: comparison of three rehabilitation programs. Journal of Rehabilitation Medicine, 34(1), 40-45.
  80. Kouidi, E., Grekas, D., Deligiannis, A., & Tourkantonis, A. (2004). Outcomes of long-term exercise training in dialysis patients: comparison of two training programs. Clinical nephrology, 61, S31.
  81. Lysaght, M. J. (2002). Maintenance dialysis population dynamics: current trends and long-term implications. Journal of the American Society of Nephrology, 13(suppl 1), S37-S40.
  82. Grassmann, A., Gioberge, S., Moeller, S., & Brown, G. (2005). ESRD patients in 2004: global overview of patient numbers, treatment modalities and associated trends. Nephrology Dialysis Transplantation, 20(12), 2587-2593.
  83. Lee, H., Manns, B., Taub, K., Ghali, W. A., Dean, S., Johnson, D., & Donaldson, C. (2002). Cost analysis of ongoing care of patients with end-stage renal disease: the impact of dialysis modality and dialysis access. American journal of kidney diseases: the official journal of the National Kidney Foundation, 40(3), 611.
  84. Goeree, R., Manalich, J., Grootendorst, P., Beecroft, M. L., & Churchill, D. N. (1995). Cost analysis of dialysis treatments for end-stage renal disease (ESRD). Clinical and investigative medicine. Médecine clinique et experimentale, 18(6), 455.
  85. Dirks, J. H., Kaseje, D., Katz, I. J., Naicker, S., Rodriguez-Iturbe, B. I., Schieppati, A., & Valdes, R. H. (2005). Prevention of chronic kidney and vascular disease: Toward global health equity-The Bellagio 2004 Declaration. Kidney International, Vol. 68, Supplement 98 (2005), pp. S1–S6

One thought Chronic kidney disease

  1. Pingback: September update

Comments are closed.