Global Policy Barriers and Enablers to Exercise and Physical Activity in Kidney Care.

OBJECTIVE: Impairment in physical function and physical performance leads to decreased independence and health-related quality of life in people living with chronic kidney disease and end-stage kidney disease. Physical activity and exercise in kidney care are not priorities in policy development. We aimed to identify global policy-related enablers, barriers, and strategies to increase exercise participation and physical activity behavior for people living with kidney disease. DESIGN AND METHODS: Guided by the Behavior Change Wheel theoretical framework, 50 global renal exercise experts developed policy barriers and enablers to exercise program implementation and physical activity promotion in kidney care. The consensus process consisted of developing themes from renal experts from North America, South America, Continental Europe, United Kingdom, Asia, and Oceania. Strategies to address enablers and barriers were identified by the group, and consensus was achieved. RESULTS: We found that policies addressing funding, service provision, legislation, regulations, guidelines, the environment, communication, and marketing are required to support people with kidney disease to be physically active, participate in exercise, and improve health-related quality of life. We provide a global perspective and highlight Japanese, Canadian, and other regional examples where policies have been developed to increase renal physical activity and rehabilitation. We present recommendations targeting multiple stakeholders including nephrologists, nurses, allied health clinicians, organizations providing renal care and education, and renal program funders. CONCLUSIONS: We strongly recommend the nephrology community and people living with kidney disease take action to change policy now, rather than idly waiting for indisputable clinical trial evidence that increasing physical activity, strength, fitness, and function improves the lives of people living with kidney disease.

Sustained exercise programs for hemodialysis patients: The characteristics of successful approaches in Portugal, Canada, Mexico, and Germany.

Despite having good intentions, hemodialysis (HD) clinics often fail to sustain exercise programs that they initiate. There are many reasons for this, including a lack of funding, inadequate training of the clinic staff, a lack of exercise professionals to manage the program or train the staff, and the many challenges inherent to exercising a patient population with multiple comorbid diseases. Despite these barriers, there are several outstanding examples of successful exercise programs in HD clinics throughout the world. The aim of this manuscript is to review the characteristics of four successfully sustained HD exercise programs in Portugal, Canada, Mexico, and Germany. We describe the unique approaches they have used to fund and manage their programs, the varied exercise prescriptions they incorporate, the unique challenges they face, and discuss the benefits they have seen. While the programs differ in many regards, a consistent theme is that they each have substantial and committed support from the entire clinic staff, including the nephrologists, administration, nurses, dietitians, and technicians. This suggests that exercise programs in HD clinics can be successfully implemented and sustained provided significant effort is made to foster a culture of physical activity throughout the clinic.

A structured exercise programme during haemodialysis for patients with chronic kidney disease: clinical benefit and long-term adherence.

OBJECTIVE: Long-term studies regarding the effect of a structured physical exercise programme (SPEP) during haemodialysis (HD) assessing compliance and clinical benefit are scarce. STUDY DESIGN: A single-centre clinical trial, non-randomised, investigating 46 patients with HD (63.2 ± 16.3 years, male/female 24/22, dialysis vintage 4.4 years) performing an SPEP over 5 years. The SPEP (twice/week for 60 min during haemodialysis) consisted of a combined resistance (8 muscle groups) and endurance (supine bicycle ergometry) training. Exercise intensity was continuously adjusted to improvements of performance testing. Changes in endurance and resistance capacity, physical functioning and quality of life (QoL) were analysed over 1 year in addition to long-term adherence and economics of the programme over 5 years. Average power per training session, maximal strength tests (maximal exercise repetitions/min), three performance-based tests for physical function, SF36 for QoL were assessed in the beginning and every 6 months thereafter. RESULTS: 78% of the patients completed the programme after 1 year and 43% after 5 years. Participants were divided--according to adherence to the programme--into three groups: (1) high adherence group (HA, >80% of 104 training sessions within 12 months), (2) moderate adherence (MA, 60-80%), and 3. Low adherence group (LA, <60%)) with HA and MA evaluated quantitatively. One-year follow-up data revealed significant (p<0.05) improvement for both groups in all measured parameters: exercise capacity (HA: 55%, MA: 45%), strength (HA: >120%, MA: 40-50%), QoL in three scores of SF36 subscales and physical function in the three tests taken between 11% and 31%. Moreover, a quantitative correlation analysis revealed a close association (r=0.8) between large improvement of endurance capacity and weak physical condition (HA). CONCLUSIONS: The exercise programme described improves physical function significantly and can be integrated into a HD routine with a high long-term adherence.

Flow cytometric measurements of neutrophil functions: the dependence on the stimulus to cell ratio.

Phagocytosis and antimicrobial killing of neutrophils has been quantitatively determined as a function of the stimulus (Candida albicans) to cell ratio R using two donor collectives containing a total of 115 blood samples. Analysis of the collectives in two different laboratories according to the same flow cytometric protocol for simultaneous measurement of neutrophil functions did not produce statistically significant differences. The number of phagocytosing leukocytes as well as that of killed fungi per leukocyte depends strongly on R. While each phagocytosing neutrophil kills one fungus at low values of R, each neutrophil kills on average 2.5 fungi for large R.

The influence of uraemia and haemodialysis on neutrophil phagocytosis and antimicrobial killing.

BACKGROUND: Neutrophil functions in haemodialysis (HD) patients are altered by uraemia and by HD procedure. We investigated details of the neutrophil dysfunction as its nature and origin is not well understood. This is reflected by conflicting results about neutrophil phagocytosis activity and by scarce data on the neutrophil killing capability in HD patients. METHODS: Using a flow-cytometric test system we have measured simultaneously phagocytosis and the production of reactive oxygen species (ROS) of neutrophils and in parallel antimicrobial killing of yeast by neutrophils. 117 whole-blood samples of healthy controls and 50 pre- and 50 post-dialysis samples of HD patients, half of them with diabetes mellitus (DM), have been evaluated. We have constructed a model to account for the dependence on the stimulus-to-cell ratio and obtain means for phagocytosis and killing at different incubation times. RESULTS: (i) HD patients have significantly lower neutrophil killing (20%) than healthy controls. (ii) Dialysis improves the killing capability by 10-15%, after dialysis the killing activity remains significantly (10%) below that of the controls. (iii) The percentage of neutrophils, which exhibit phagocytosis and produce ROS, does not differ significantly between HD patients and healthy controls. (iv) Age has no significant influence on phagocytosis and killing. CONCLUSION: The neutrophil killing capability is reduced in HD patients while the amount of neutrophils that phagocyte and produce ROS remains unchanged. Functional impairment of uraemic neutrophils is therefore mainly a result of their reduced capability to kill microorganisms intracellularly.