Exercise Training in Chronic Kidney Disease group exercising on off-dialysis days at the gym showed the greatest


improvement in VO2max compared with the groups exercising at home and during dialysis, respectively. However, adherence to the exercise program was highest in the latter two groups, with a withdrawal rate of 15% after six months compared with 25% for the group exercising at the gym on off-dialysis days.42


The patient’s physician should prescribe exercise training after an evaluation of risk factors and after setting the goal together with the patient. Is the aim to be able to work, to manage the home, to continue to live at home and care for oneself, or to be able to carry on one’s social and recreational activities or to get into shape for a renal transplant?


The exercise training regime depends on the patient’s medical and functional status and goal. Roughly, there are three modes of training: aerobic training, which increases cardiac output; resistance training for muscle strength and endurance; and functional training in order to cope with the demands of everyday living. Aerobic training comprises walking, running, cycling, and swimming. Resistance training consists of weight lifting, using the arms or legs with weight cuffs around the ankles, or therabands, which are especially useful during dialysis and when patients have no access to a gym. Functional training helps train balance and co-ordination and comprises walking on a treadmill, walking up stairs, standing on balance mats, doing knee bends, and getting up from sitting to standing, to name just a few exercises.


In order to administer an adequate dose of exercise training without any risk to the patient, especially for those with a number of comorbidities, Borg’s scale of perceived exertion is very useful.43,44 This is a scale ranging from 0 to 20, where the patient rates the subjective level of exertion as perceived, with 0 being ‘no exertion at all’ and 20 ‘unbearably hard’. The recommendation from the European Association of Rehabilitation in Chronic Kidney Disease is to keep the patient at a level of 13, which is ‘fairly hard’. This has a good exercise training effect and entails basically no risk. The scale has been developed for the graded exercise test and is highly correlated


1. Clyne N, et al., Nephron, 1994;67:322–6. 2. Painter P, et al., Nephron, 1986;41:47–51. 3. Foley RN, et al., Am J Nephrol, 2007;27(3):279–86. 4. Parfrey PS, et al., Nephrol Dial Transplant, 1996;11(7): 1277–85.


5. Foley RN, et al., Am J Kidney Dis, 1998;32(5)(3):S112–S119. 6. Sandvik L, et al., N Engl J Med, 1993;(328):533–7. 7. Paffenbarger RS, et al., N Engl J Med, 1993;328:538–45. 8. Stack AG, et al., Am J Kidney Dis, 2005;45:690–701. 9. Sietsema KE, et al., Kidney Int, 2004;65:719–24. 10. O’Hare AM, et al., Am J Kidney Dis, 2003;41:447–54. 11. Goldberg AP, et al., Kidney Int, 1983;24(16):S303–S309. 12. Painter P, et al., Nephron, 1986;43:87–92. 13. Clyne N, et al., Nephron, 1991;59:84–9. 14. Ota S, et al., Geriatr Nephrol Urol, 1996;5:157–65. 15. Kouidi E, et al., Nephrol Dial Transplant, 1998;13:685–99.


with VO2max; however, in our hands it has been shown to be extremely useful in prescribing an adequate dose of exercise training


irrespective of whether aerobic or resistance training is involved.


Preferably, the physician prescribes exercise training and the nephrological physiotherapist or exercise physiologist designs the program and evaluates the patient’s progress regularly. The actual training schedule can be administered by the physiotherapist/exercise physiologist, staff on the dialysis ward, or by the patient him/herself depending on functional level. Yet, most important of all for the group of severely functionally impaired patients is to encourage and utilize all opportunities for movement and weight-bearing, such as walking with or without assistance from the scales to the dialysis bed, standing up and sitting down a number of times, or extending and flexing the leg while sitting in a chair.


Conclusion


Maintenance dialysis is an expensive treatment; medication and transportation to and from the dialysis unit are costly. Exercise training increases patients’ independence, wellbeing and mobility, decreases the necessity for a number of medications, and has been associated with better survival and probably less hospitalization. However, it involves specialized physiotherapists or exercise physiologists, but is cost-effective and very efficacious in the long run. Doctors must start prescribing it, nurses must start encouraging it, and healthcare providers must start financing it. n


Naomi Clyne, MD, PhD, is an Associate Professor and Director of the Department of Nephrology at Skåne University Hospital in Lund. She is Co-founder and Chairman of the European Association of Rehabilitation in Chronic Kidney Disease (EURORECKD). She is a member of the Swedish Association of Nephrology, the European Renal Association- European Dialysis and Transplant Association (ERA-EDTA), the International Society of Nephrology (ISN) and the American Society of Nephrology (ASN). Professor Clyne’s research interests comprise exercise training in chronic kidney disease (CKD) patients and the clinical effects of erythropoietic-stimulating agents. Another professional interest is leadership of and the organization of healthcare.


16. Castaneda C, et al., Am J Kidney Dis, 2004;43:607–16. 17. Heiwe S, et al., Nephron, 2001;88:48–56. 18. Koufaki P, et al., Clin Physiol & Func Im, 2002;22:115–24. 19. Deligiannis A, et al., Int J Cardiol, 1999;70:253–66. 20. Deligiannis A, et al., Am J Cardiol, 1999;84:197–202. 21. Boyce ML, et al., Am J Kidney Dis, 1997;30:2:180–92. 22. Miller BW, et al., Am J Kidney Dis, 2002;39(4):828–33. 23. Goldberg AP, et al., Am J Clin Nutr, 1980;33:1620–8. 24. Carney RM, et al., Nephron, 1987(47):194–8. 25. Kouidi E, et al., Nephron, 1997(77):152–8. 26. Levendoglu F, et al., J Nephrol, 2004;17:826–32. 27. Painter P, et al., J Kidney Dis, 2000;35(3):482–92. 28. Molsted S, et al., Nephron Clin Pract, 2004;96:c76–c81. 29. Osato S, et al., Nephron, 1990;55:306–11. 30. Robinson-Cohen C, et al., Arch Int Med, 2009;169:22: 2116–23.


31. Davies TA, et al., Kidney Int, 1983;24(16):S52–S57. 32. Garibotto G, et al., Kidney Int, 1994;45:1432–9. 33. Siew ED, et al., Kidney Int, 2007;71:146–52. 34. Pupim LB, et al., Kidney Int, 2005;68(5):2368–74. 35. Majchrzak K, et al., Nephrol Dial Transplant, 2007;23:1362–9. 36. Pupim LB, et al., Am J Physiol Endocrinol Metab, 2004;286:E589–E597.


37. Castaneda C, et al., Am J Kidney Dis, 2004;43:4:607–16. 38. Cheema B, et al., J Am Soc Nephrol, 2007;18:1594–1601. 39. Klang B, et al., Quality of Life Research, 1996;5:109–16. 40. Hagren B, et al., J Advanced Nursing, 2001;34(2):196–202. 41. Ross DL, et al., Am J Nephrol, 1989;9:376–83. 42. Konstantinidou E, et al., J Rehab Med, 2002;34(1):40–6. 43. Borg G, Scand J Rehab Med, 1970;23:92–8. 44. Borg G, Physiology: From Research to Practice, London: Plenum, 1978;333–51.


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