# Exercise as it relates to Disease/The effects that physical activity has on chronic kidney disease patients

This is a critique of the research article "Evaluation of a pragmatic exercise rehabilitation program in chronic kidney disease" by Sharlene A. Greenwood, Herolin Lindup, Kevin Taylor, Pelagia Koufaki, Robert Rush, Iain C. Macdougall, Thomas H. Mercer

### What is the background to this research?

Chronic kidney disease (CKD) is a long-term condition that can be debilitating. Many patients can experience physical and mental effects, which are side effects of the disease. These symptoms include; fatigue, muscle weakness, and reduced ability to perform daily activities. Physical activity is recommended in several national chronic kidney disease (CKD) guidelines, but its incorporation into routine care has been slow. The translation of research-led physical activity programs into an established procedure appears to be a particular obstacle.

### Where is the research from?

The research is based on a study that was done by the King’s College Hospital Research Ethics Committee.

### What kind of research was this?

It is an exploratory uncontrolled study design, which was held over a period of 12 weeks. This was to evaluate the effectiveness and practicality of pragmatic exercise program appropriate for the delivery of CKD patients. Adult CKD patients (over the age of 18) at various stages of CKD, pre-dialysis (CKD stages 3-4), receiving maintenance haemodialysis (CKD stage 5) and post transplants, under the care of the renal unit at King’s College Hospital, were considered eligible for the program. The exclusion criteria included unstable angina, acute left ventricular failure, a serious cardiac event in the preceding 6 weeks, uncontrolled cardiac arrhythmias, and uncontrolled hypertension. The Demographic data, including age, sex, and stage of kidney disease, were collected.

### What did the research involve?

The present study aimed to gauge if exercise capacity and functional ability could be improved in patients who completed a pragmatically constructed 12-week RR program. The overall objective was to explore whether a pragmatic, supervised outpatient exercise program could be feasibly implemented as an effective approach to improving aspects of activities of daily living-related functional capacity in a group of patients spanning the entire CKD trajectory.
This study also included observations about whether exercise influenced their mood and reduced the patients' anxiety and depression. The research/study involved adult CKD patients over the age of 18 at various stages of CKD, including pre-dialysis (PD) (stages 3-4), receiving maintenance haemodialysis (stage 5), and post-transplants (stage 5). So having a great support system will be beneficial for that post-transplant going through this 12-week RR program.

### What were the basic results?

The results from this RR program are comparable with exercise and functional capacity outcome improvements reported following pulmonary and cardiac rehabilitation programs. These showed significant improvements in aerobic capacity ranging from 21% to 43% in dialysis patients in stage 5, lasting from 3-6 months. It also showed that fifty-four out of the 131 patients who participated in the RR program failed to complete 12 or more of the 24 scheduled sessions. This could be due to many different factors inducing; motivation to participate in all sessions as the patients may not have seen them as an important part of their rehabilitation stage, as this was only a study. It could be that the patient wasn’t feeling well enough on the day the sessions were held; another reason could also be that the participant may not have been used to doing a certain amount of exercise even before the disease.
While the study shows that physical exercise helps to improve physical health, it has also shown that it improves the individual's mental health. Participants who completed the RR program demonstrated improvements in the mean level of anxiety (16%) and depression (28%), as measured with the HAD score (Table 3). This finding is consistent with two previous studies of HD patientsthat demonstrated improvements in anxiety and mental health scores using the SF-36 Quality of Life Scale and supports the observations of Kouidi et al., who reported a significant improvement in the HAD score of 23% in patients who completed their 1-year HD exercise program.

#### Limitations

* It’s reflected in only one RR program.
* Due to the lack of the control design it prevented the comparison of changes in exercise capacity, functional ability, and BMI in those patients that chose to participate in the RR program with those who did not enroll in this type of program, and therefore there is a selection bias in favour of those patients who are motivated enough already to enroll in a 12-week program.
* The results from the RR program suggest that this multi-disciplinary program can achieve improvements in exercise capacity and functional ability in CKD patients, potentially giving them the opportunity of returning to work and increasing physical functioning, with the associated benefits of this. This can give many patients a sense of false hope, especially when they don't end up meeting certain goals of theirs.
* The self-reported fitness level and the patient's age may predict who will most likely complete this program, therefore making it biased.

### What conclusions can we take from this research?

This study has shown improvements in participants' health both physically and mentally during the 12-week RR program. While fifty four of the patients failed to complete 12 or more of the 24 scheduled sessions, this could've been due to the fact that the participants just didn't have a strong enough support system to help them with the completion of this study as chronic kidney disease can be debilitating when it's in the late stages. Those who completed 12 or more sessions found reduced signs of depression and anxiety. This is because exercise has been proven to increase one's self-esteem and cognitive function.

### Practical advice

* Physical activity not only promotes a healthier lifestyle, physically and mentally, but it also helps to improve on reducing greater risk factors for this population.
* The program did not result in any injuries from the participants, deeming it safe for this population. Caretakers of chronic kidney disease (CKD) should therefore take a similar approach to a program like the one implemented in this study.

### Further information/resources

For further information on this topic, please visit:
* https://www.mayoclinic.org/diseases-conditions/chronic-kidney-disease/symptoms-causes/syc-20354521
* https://www.aihw.gov.au/reports/chronic-kidney-disease/chronic-kidney-disease/contents/summary
* https://www.medicalnewstoday.com/articles/172179#stages

### References

* 1 2 3 4 5 https://academic.oup.com/ndt/article/27/suppl_3/iii126/1823314?login=false
* ↑ Storer TW, Casaburi R, Sawelson S, et al. Endurance exercise training during haemodialysis improves strength, power, fatigability and physical performance in maintenance haemodialysis patients, Nephrol Dial Transplant, 2005, vol. 20 (pg. 1429-1437)
* ↑ Kouidi E, Iacovides A, Iordanidis P. Exercise renal rehabilitation program: psychosocial effects, Nephron, 1997, vol. 77 (pg. 152-158)
* ↑ Konstantinidou E, Koukouvou G, Kouidi E , et al. Exercise training in patients with end-stage renal disease on hemodialysis: comparison of three rehabilitation programs, J Rehabil Med, 2002, vol. 34 (pg. 40-45)
* ↑ Oh-Park M, Fast A, Gopal S. Exercise for the dialyzed: aerobic and strength training during hemodialysis, Am J Phys Med Rehabil, 2002, vol. 81 (pg. 814-821)
* ↑ Painter P, Carlson L, Carey S, et al. Physical functioning and health related quality-of-life changes with exercise training in hemodialysis patients, Am J Kidney Dis, 2000, vol. 35 (pg. 482-492)