Effect of a 3-Year Lifestyle Intervention in Patients with Chronic Kidney Disease: A Randomized Clinical Trial
Authors: Beetham Kassia S. , Krishnasamy Rathika , Stanton Tony , Sacre Julian W. , Douglas Bettina , Isbel Nicole M. , Coombes Jeff S. , Howden Erin J. 
Published: December 2021

Significance Statement
Modifiable risk factors, such as low physical activity, contribute to cardiovascular mortality in patients with CKD. In a randomized trial of 160 patients with CKD, a nurse-led, multidisciplinary lifestyle intervention that included exercise training significantly increased cardiorespiratory fitness (peak O2 uptake) in patients with CKD at 12 months compared with usual care; peak O2 uptake declined to near baseline levels thereafter but remained elevated compared with usual care after 3 years of follow-up. The intervention also markedly increased exercise capacity and physical function, and prevented adverse anthropometric changes that were observed in the usual care group. Importantly, benefits of the intervention were sustained over 3 years. This study provides evidence of the effectiveness of a multidisciplinary team–supported lifestyle intervention in enhancing the health of patients with CKD.

Background
Supervised lifestyle interventions have the potential to significantly improve physical activity and fitness in patients with CKD.

Methods
To assess the efficacy of a lifestyle intervention in patients with CKD to improve cardiorespiratory fitness and exercise capacity over 36 months, we conducted a randomized clinical trial, enrolling 160 patients with stage 3–4 CKD, with 81 randomized to usual care and 79 to a 3-year lifestyle intervention. The lifestyle intervention comprised care from a multidisciplinary team, including a nephrologist, nurse practitioner, exercise physiologist, dietitian, diabetes educator, psychologist, and social worker. The exercise training component consisted of an 8-week individualized and supervised gym-based exercise intervention followed by 34 months of a predominantly home-based program. Self-reported physical activity (metabolic equivalent of tasks [METs] minutes per week), cardiorespiratory fitness (peak O2 consumption [VO2peak]), exercise capacity (maximum METs and 6-minute walk distance) and neuromuscular fitness (grip strength and get-up-and-go test time) were evaluated at 12, 24, and 36 months.

Results
The intervention increased the percentage of patients meeting physical activity guideline targets of 500 MET min/wk from 29% at baseline to 63% at 3 years. At 12 months, both VO2peak and METs increased significantly in the lifestyle intervention group by 9.7% and 30%, respectively, without change in the usual care group. Thereafter, VO2peak declined to near baseline levels, whereas METs remained elevated in the lifestyle intervention group at 24 and 36 months. After 3 years, the intervention had increased the 6-minute walk distance and blunted declines in the get-up-and-go test time.

Conclusions
A 3-year lifestyle intervention doubled the percentage of CKD patients meeting physical activity guidelines, improved exercise capacity, and ameliorated losses in neuromuscular and cardiorespiratory fitness.