Management Of Exercise Rehabilitation in Patients With Chronic Kidney Disease

Chronic kidney disease (CKD) patients will experience different degrees of dysfunction with the decline of renal function, greatly increasing the risk of poor prognosis in CKD patients, and bringing a heavy economic and nursing burden to families and society. Therefore, improving and improving the physiological function and quality of life of CKD patients has become an important issue faced by the majority of clinical and rehabilitation medical personnel. 

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Studies have shown that exercise rehabilitation training (ERT) is an important measure to improve physiological function, reduce muscle atrophy and improve cardiorespiratory endurance in patients with CKD. Regular ERT can improve body function, muscle strength, and health-related quality of life in patients with CKD, reduce inflammatory state, and delay the progression of renal function.

Evaluation before ERT

CKD patients are a high-risk group for cardiovascular disease. Before implementing ERT, it is particularly important to do a good job of evaluation to reduce ERT-related adverse events. Common evaluation strategies include the following.

Indication evaluation

For any CKD patient with functional impairment, an ERT program should be initiated as soon as possible.

Clinical status assessment

Evaluation of the clinical status of CKD patients should include (1) medical history evaluation, living habits, exercise habits, family history, etc.; (2) physical examination; (3) laboratory examinations.

Athletic ability assessment

To evaluate cardiorespiratory endurance, muscle strength, muscle endurance, flexibility, and other aspects of CKD patients.

Implementation of ERT

Sign the informed consent

An informed consent form for ERT should be signed with CKD patients or their guardians, explaining the content, method, time, plan, etc. of ERT, and should inform the relevant risks and benefits.

Create ERT documents

An ERT file should be established for each CKD patient, including but not limited to the patient's basic information, primary disease of CKD, medication history, family history, physical and laboratory examinations, functional disability assessment results, and ERT prescription plans.

ERT common facilities

ERT commonly used soft cushions or yoga mats, pedals, dumbbells, sandbags, elastic bands, balance balls, power bicycles, recumbent rehabilitation bicycles, pedometers or sports bracelets, etc.

ERT implementation strategy

The basic components of ERT: are warm-up, ERT, finishing activities, stretching, and other parts.

ERT basic prescribing principles:

Exercise frequency (frequency), intensity (intensity), time (time), type (type), total volume (volume), and progression (progression), namely FITT-VP, are formulated based on the principles.

① Exercise frequency: At least 3 to 5 times of exercise training is required per week. 

② Exercise intensity: low to moderate intensity exercise is recommended, or an RPE score of 11 to 16 points. 

③ Exercise time: The target time is 20-60 minutes for each exercise, which can be carried out in stages according to the individual conditions of CKD patients. 

④ Exercise type: including aerobic exercise, resistance exercise, and flexibility training. 

⑤ Total amount of exercise: The recommended total amount of aerobic exercise for most adult CKD patients is Greater than or equal to 500-1000 METs-min/week, or at least 150 min/week (or weekly energy consumption of 1000 kcal) of moderate-intensity exercise, or daily 5400 to 7900 steps. 

⑥ Exercise Advanced: At the beginning of ERT, the principles of the low initial dose, gradual progress, and persistence should be emphasized. During ERT, if the patient develops severe chest tightness or dyspnea, unrelieved fatigue and muscle pain, angina pectoris or severe arrhythmia, and the blood pressure during exercise decreases by 20 mmHg from the baseline value, ERT needs to be stopped or the exercise prescription should be adjusted.

ERT for special populations

Hemodialysis (HD) patients

HD patients have complex conditions and many clinical comorbidities. Before formulating exercise rehabilitation prescriptions, HD patients should be comprehensively evaluated: (1) disease state; (2) cardiovascular disease risk factors; (3) motor function. The prescription should include exercise type, exercise intensity, exercise frequency, and exercise duration. ERT is an integral part of the comprehensive management of HD patients. Simple exercise training can improve the patient's physiological function, reduce HD-related complications, and reduce nursing costs and hospitalization costs. HD patients should be encouraged to start with a walking program and gradually establish and complete moderate-intensity exercise training 3 to 5 times per week and 30 min per time, so that they can change from passively receiving treatment to actively pursuing ERT.

Peritoneal Dialysis (PD)

Patients should evaluate the physical, mental, verbal, and social functions of PD patients before and after ERT, to select appropriate exercise methods, formulate individual exercise prescriptions, and regularly evaluate the effect of exercise therapy. Commonly used assessments in PD patients are activities of daily living, cardiorespiratory endurance, muscular endurance, and quality of life. PD patients can choose to start with low to moderate exercise intensity, 3 times per week, and the exercise intensity is 11 to 13 points on the subjective fatigue perception score. Exercise methods include aerobic exercise, resistance exercise, and aerobic combined resistance exercise. PD patients may choose between a dialysis center-supervised exercise program or home exercise rehabilitation.

Kidney transplant recipient

(1) Exercise method: the exercise of suitable intensity should be selected according to the recipient's state, such as walking, jogging, Tai Chi, gymnastics, long-distance running or mountain climbing, and other exercises of different intensities. 

(2) Type of exercise: You can choose to increase physical exercise, exercise to increase limb strength, exercise to increase muscle strength, respiratory muscle training, and exercise to increase endurance intensity. 

(3) Exercise time: 1 to 2 times moderate-intensity rehabilitation exercise every day, 10 to 30 minutes per exercise, 3 to 5 minutes of rest in the middle, and aerobic exercise 3 to 5 times a week. The specific situation is adjusted according to the recipient's own state and feeling. 

(4) Effect evaluation: physiological function, physical function, social function, emotional function, psychological function, general health status, etc. 

(5) Methods to improve the efficacy of exercise: Rehabilitation exercise therapy must be adhered to for 3 to 6 months to be effective, and the recipients should be encouraged to persevere and persevere in exercising on their own.

ERT Education Program

Good health education can increase patient compliance, improve patient participation enthusiasm, and achieve the effect of rehabilitation treatment. According to different preferences of patients, medical staff can formulate suitable exercise programs, choose favorite sports, and arrange exercise time according to patients' living habits. To ensure the safety and effectiveness of rehabilitation exercise therapy, the amount, time, and frequency of exercise should also be adjusted in time according to the patient's physical condition.

Summary: A large number of studies have confirmed that low-to-moderate-intensity exercise training is beneficial to the control of blood lipids and blood pressure in CKD patients, improves the psychological state, and improves the physiological function, cardiorespiratory endurance, and quality of life of patients. Therefore, clinicians should formulate individualized ERT prescriptions and education plans according to the patient's condition, to delay the progression of CKD, reduce cardiovascular and cerebrovascular complications, and reduce the incidence of end-stage renal disease and death.

for more information:Ali.ma@wecistanche.com