# Exercise as it relates to Disease/Benefit of exercise for chronic kidney disease
### Prevalence

Chronic Kidney Disease (CKD) was the 10th leading cause of death in Australia in 2011. Approximately 1.7 million Australian (1 in 10) aged 18 years and over have indicators of CKD such as reduced kidney function and/or the presence of albumin in the urine.

### What is Chronic Kidney Disease?

CKD is a syndrome that is associated with low glomerular filtration rate. It is now widely accepted as risk factor for cardiovascular disease (CVD), kidney failure and mortality. CKD is often associated with non-conventional risk factors such as anemia and serum calcium and phosphate disturbances, which are proportional to CKD stages. There are five CKD stages:
| Stages | | Glomerular Filtration Rate |
| 1 | Small amount of kidney damage | >90 ml/min |
| 2 | Mild kidney damage | 60-89 ml/min |
| 3 | Moderate kidney damage | 30-59 ml/min |
| 4 | Severe kidney damage | 15-29 ml/min |
| 5 | Kidney failure or End Stage Renal Disease (ESRD) | <15 ml/min |

### Causes of Chronic Kidney Disease

It is normally characterized by slowly worsening albuminuria, hypertension and progressive decline in glomerular filtration rate (GFR), sometimes with nephrotic syndrome. Common causes of CKD are glomerular and tubulointerstitial diseases resulting from infections and exposure to drugs and toxins
These comorbidities significantly increase the chance of CKD, and stem from risk factors such as:
| Fixed | Behavioural | Biomedical |
| * Family history and genetics * Increasing age * Previous kidney disease or injury * Low birth weight * Male sex | * Tobacco smoking * Physical inactivity * Poor nutrition | * Diabetes * High blood pressure * Cardiovascular disease * Overweight and obesity * Systematic kidney inflammation |

## Treatment

* Lifestyle modifications, such as weight reduction, exercise and dietary are essential for patients with CKD. Weight reduction is effective for proteinuria reduction in obese patients
* In term of pharmacological approaches, there is a wide range of options that offer the possibility of slowing progression. However, control of hypertension is the most effect effective intervention. Control of proteinuria and the inhibition of the renin-angiotensin system are important factors in slowing the progression of diabetic and non-diabetic CKD
* Dialysis and transplantation are effective but the high cost restrict its availability worldwide hence leaving many patients with kidney failure die without treatment

## Exercise As An Intervention: Aerobic Exercise vs. Resistance Training

| Aerobic Exercise | Resistance Exercise |
| Improves: * Energy level * Peak oxygen consumption * Decrease of blood pressure * Muscle strength and functional capacity * Capillarisation Impact on Quality of Life: * Decreased depression and anxiety * Improve physical functioning for regular life-readiness activities Main Goal: To improve aerobic fitness and reduce fatigue | Improves: * Increase muscle fibers (both type I and II) * Maintenance of body weight * Muscle strength Impact on Quality of Life: * Improves strength to perform heavy tasks * Improve the ability to live independently in the geriatric population Main Goal: To improve musculoskeletal strength |

### Limitations and Considerations

Once a patient pregresses to ESRD, as renal placement therapy has a paradoxical effect on survival, weight reduction may no longer be indicated. Therefore, a higher BMI has a beneficial effect on survival in ESRD

## Exercise Recommendation

Patients should visit the care team prior to exercise for exercise and physical functioning consideration. Patients should be regularly assessed to determine their level of cardiac risk factors, physical functioning so that a training program can be appropriately prescribed.

### Aerobic Exercise

* Low to moderate intensity aerobic exercise 3 or more times per week.
* Exercise should begin at low intensity (50-60% of peak heart rate) and short duration (10–20 minutes per session)

### Resistance Training

* Should be initiated at low intensity and progressed gradually as tolerated
* Base on 3RM or higher to avoid tendon injuries
* All major muscle groups should be trained in 3 sessions per week
Warm-up and cool-down sessions of 5 to 10 minutes should proceed and follow each aerobic or resistance in each session. Stretching or yoga could assist in flexibility, balance, coordination and improving gait.

## Further reading

For further information regarding Chronic Kidney Disease, contact your health care professional or visit:
* Kidney Health Australia, Chronic Kidney Disease Management in General Practice
* Royal College of Physicians (UK), National Clinical Guideline for Early Identification and Management in Adults in Primary and Secondary Care: Chronic Kidney Disease

## References

* ↑ Australian Bureau of Statistics. Australian Health Survey: Biomedical Results for Chronic Diseases, 2011-12. 2013. Report No.: 4364.0.55.005.
* 1 2 3 Iseki,Kunitoshi (2008). Chronic Kidney Disease in Japan. Internal Medicine. Vol 47(8), pp. 42 - 49.
* 1 2 Andrew S. Levey, Josef Coresh (2012). Chronic Kidney Disease. The Lancet, Vol 379(9811) pp. 165 - 180.
* ↑ AIHW (2010). Chronic kidney disease risk factors. http://www.aihw.gov.au/ckd/risk-factors/
* ↑ A Meguid El Nahas, Aminu K Bello (2005). Chronic kidney disease: the global challenge. The Lancet, Vol 365(9456), pp 331 – 340.
* ↑ Irfan Moinuddin, David J. Leehey (2008). A Comparison of Aerobic Exercise and Resistance Training in Patients With and Without Chronic Kidney Disease
* ↑ Kirsten L. Johansen(2005)Exercise and Chronic Kidney Disease: Current Recommendations. Sports Med, Vol 35(6), pp 485-499