# Exercise as it relates to Disease/Resistance exercise for patients with end-stage renal disease
### What is end-stage renal disease?

End-stage renal disease (ESRD), also known as Stage 5 renal disease, is a classification of kidney dysfunction in which the individual must undertake external filtering and cleansing of the blood via hemodialysis for a period of greater than three months. It is the most severe form of kidney disease as without hemodialysis treatment the kidneys would be unable to adequately sustain life.

### What are the causes of end-stage renal disease?

There are three primary causes of ESRD. They are as follows:
* Diabetes - without the action of insulin to regulate blood sugar levels, large volumes of blood sugar can accumulate in the kidneys and damage the blood-filtering capillaries.
* Glomerulonephritis - inflammation of the glomerulus reduces their proficiency in filtering waste products and excess fluids from the blood leading to impaired kidney function.
* Hypertension - the reduction in blood supply to the kidneys due to thickening of the capillary walls and narrowing of the vessel diameter compromises their ability to function optimally.

### Effects associated with end-stage renal disease

* Cachexia (atrophy of skeletal muscle and other tissue);
* Secondary anemia (red blood cell deficiency);
* Depression;
* Cardiac abnormalitites.

## What is Resistance Exercise?

Resistance exercise involves the use of an external force or load to oppose movements made by the body. It is traditionally used to increase strength and size of skeletal muscles and is prescribed in a progressive-overload manner to ensure constant adaptations are being made.

## Benefits of Resistance Exercise

Although hemodialysis is an essential treatment option for end-stage renal disease patients, it is often associated with decreased levels of physical fitness, psychosocial deficits and meagre quality of life. Atrophy of skeletal muscle is a particularly adverse ramification of hemodialysis therapy as illustrated by its high correlation with mortality in the ESRD population. The prescription of resistance exercise may therefore be a beneficial intervention to oppose muscle wasting and promote longevity for ESRD patients.
Proposed benefits of resistance exercise for ESRD patients include the following:
* Increases in muscle quality;
* Increases in total strength;
* Improvements in body weight and BMI (body mass index);
* Improved physical function;
* Enhanced vitality and quality of life.

## Recommended Implementation

The justification for prescribing resistance exercise to counter muscle degeneration in the ESRD population is well established. There are however physical barriers which could potentially impede this. In particular the inactivity inherited as a result of spending 12 to 18 hours per week receiving hemodialysis treatments. It should be encouraged however that the sedentariness occurring during these periods be substituted with a tailored resistance exercise program to combat the accelerated muscle wasting process. Current evidence suggests that physical activity levels of >30 min/session three times/week are needed to elicit fitness and quality of life responses. However given the diminished physical capacity ESRD patients exhibit, Exercise and Sports Science Australia (ESSA) specifically developed recommendations as to how these patients should proceed when commencing a resistance exercise program. They specifically advocate resistance exercise for individuals who exhibit cachectic qualities. They also advise that the activities included in the program are able to be performed in a seated position so as to allow the patient to exercise whilst undergoing dialysis. The patient must then complete the following screening tools:
    1. Thorough medical review including medical history, cardiovascular and blood pressure profiles.
    2. Detailed medication history with information regarding potential biochemical, hematological and medication-exercise interactions.
    3. Cardiopulmonary evaluation by virtue of an ECG (electrocardiogram) to determine suitability for the program and individual necessities.
The following is ESSA's protocol for resistance exercise which can be administered upon satisfactory completion of the aforementioned screening tools:
| | ESRD inter-dialysis | ESRD intra-dialysis | Non-dialysis |
| Initial frequency per week | Two non-consecutive days | Two non-consecutive days | Two non-consecutive days |
| Muscle groups/ # of exercises | Major muscle groups/8-12 exercises | Major muscle groups/up to 12 or as many as possible during dialysis session | Major muscle groups/8-12 exercises |
| Initial volume | 1 set to fatigue, 12–15 reps or 60–70% repetition maximum | 1 set to fatigue, 12–15 reps or 60–70% repetition maximum | 1 set to fatigue, 12–15 reps or 60–70% repetition maximum |
| Timing | Non-dialysis days | Before or during dialysis | As comfortable |
| Modality | Weight-bearing activity (light dumbbells, thera-bands, machine exercises) | Weight-bearing activity (light dumbbells, thera-bands, machine exercises) - as practical as possible | Weight-bearing activity (thera-bands, free weights, machine exercises) |
In summary, resistance exercise (if conducted appropriately) is a beneficial mode of physical activity in the ESRD population to resist the insidious process of muscle wasting and improve quality of life.

## Further reading

For more information regarding end-stage renal disease contact your health care professional or visit:
* Kidney Health Australia - http://www.kidney.org.au/
* Kidney Health Australia Video - http://www.youtube.com/user/KidneyHealthAus
* AIHW: End-stage kidney disease - http://www.aihw.gov.au/ckd/end-stage-kidney-disease/#q01
* Medline Plus: End-stage kidney disease - http://www.nlm.nih.gov/medlineplus/ency/article/000500.htm

## References

* ↑ Bellamo, R et al. (2004). Acute renal failure – definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Critical Care. Vol 8. Pp 204-212.
* 1 2 3 Australian Institute of Health and Welfare, Authoritative information and statistics to promote better health and wellbeing (2013). Australian Government.
* 1 2 Knap, B et al. (2005). Regular Exercise as a Part of Treatment for Patients With End-stage Renal Disease. Therapeutic Apheresis and Dialysis. Vol 9. Pp 211-213.
* 1 2 Kouidi, E et al. (1998). The effects of exercise training on muscle atrophy in haemodialysis patients. Nephrology Dialysis Transplantation. Vol 13. Pp 685-699.
* ↑ Daniels, J. (1995). Variable resistance exercise device. US 5409435 A.
* ↑ Deligiannis, A et al. (2002). EXERCISE TRAINING IN PATIENTS WITH END-STAGE RENAL DISEASE ON HEMODIALYSIS: COMPARISON OF THREE REHABILITATION PROGRAMS. Journal of Rehabilitation in Medicine. Vol 34. Pp 40-45.
* 1 2 Cheema, B et al. (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. Vol 18. Pp 1594-1601.
* 1 2 3 4 5 Johansen, K. (2007). Exercise in the End-Stage Renal Disease Population. Journal of the American Society of Nephrology. Vol 18. Pp 1845-1854.
* 1 2 3 4 5 Smart, N et al. (2013). Exercise & Sports Science Australia (ESSA) position statement on exercise and chronic kidney disease. Journal of Science and Medicine in Sport. Vol 16. Pp 406-411.