Johansen_subbed.qxp 31/7/09 02:59 Page 72
Dialysis
patients with ESRD. Older patients and those with more advanced after the home-based activity portion of the intervention. In addition,
kidney disease appear to have worse physical functioning, but these the authors noted that those who reported the lowest functioning at
factors cannot be easily modified. However, there is some suggestion the beginning of the study derived the most benefit from
that a higher dose of dialysis or more frequent dialysis may be participation.
43
This study suggests that it is possible to increase the
associated with better function,
8
and studies are under way to level of physical activity among patients receiving dialysis and that
determine whether more frequent dialysis can improve physical doing so can have an impact on their poor functioning.
functioning.
31
On the other hand, participation in physical activity is a
behavior that can be measured and has the potential to be modified. In summary, patients on dialysis, particularly those who are older, have
However, the nephrology community is not focusing on sedentary poor physical functioning and low participation in physical activity.
behavior as a target for improving outcomes. Few nephrologists Increasing the level of participation in moderate intensity physical
routinely assess the levels of physical activity of their dialysis patients activity has been shown to improve functioning in the dialysis
and counsel inactive patients to become more active.
32
population, but nephrologists are not implementing programs to
address this concern. The recent emphasis on measurement of quality
Increasing physical activity in this population is by no means an easy of life, including physical functioning, is a promising beginning. Given the
proposition, given the advanced age and high level of comorbidity association between sedentary behavior and poor physical functioning
and frailty that have been discussed, but higher levels of physical and the evidence that those who have low physical functioning are at
activity have the potential to improve physical functioning, quality of risk for bad outcomes, the next steps should be an assessment of
life, and possibly even survival.
25
It is surprising that although there physical activity and counseling to increase activity. Physician
have been numerous studies involving vigorous exercise training involvement increases the chances that patients will increase and
among dialysis patients, there are very few studies of increasing sustain their level of physical activity. There have been few studies of the
physical activity in a way that could be accessible to the frail or experience of CKD patients with physical activity, but some patients cite
disabled patients who may benefit most. lack of encouragement from their healthcare team as a barrier to
exercise participation.
44
Patients often receive subtle or not-so-subtle
A notable exception is a study by Painter et al. that included a home- messages from their physicians that they are not capable of being
based exercise intervention followed by a dialysis-unit-based active. Asking about and encouraging physical activity should be part of
intervention.
42
The home-based exercise included some flexibility our routine care for these patients. ■
exercises and light weight-lifting, but was mostly centered around
cardiovascular exercise, which was primarily walking, though some
Kirsten L Johansen, MD, is an Associate Professor of Medicine in Residence at the
participants used a stationary cycle. Self-reported physical functioning
University of California, San Francisco (UCSF) and Director of Dialysis at the San Francisco
and physical performance were assessed at the beginning, after the VA Medical Center. She is Director of the US Renal Data System Nutrition Special Studies
home-based regimen, and at the end of the study. The exercise group
Center and the Deputy Director of the Rehabilitation/Quality of Life Special Studies Center.
Dr Johansen’s research interests focus on physical functioning, muscle function, nutrition,
increased their participation in physical activity and improved their
and quality of life among patients with chronic kidney disease.
functioning. Most of the benefit in functioning was already evident
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72 US NEPHROLOGY
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