Gait Speed and Mortality, Hospitalization, and Functional Status Change Among Hemodialysis Patients: A US Renal Data System Special Study.

BACKGROUND: Slow walk (gait) speed predicts functional decline, institutionalization, and mortality risks in the geriatric population. A gait speed evidence base for dialysis patient outcomes is needed. STUDY DESIGN: Prospective cohort study. SETTING & PARTICIPANTS: 752 prevalent hemodialysis (HD) patients aged 20 to 92 years evaluated in 2009 to 2012 in 7 Atlanta and 7 San Francisco clinics in a US Renal Data System special study. PREDICTOR: Usual walk speed in meters per second, categorized as ≥0.6 m/s (baseline n=575), <0.6 m/s (baseline n=94), and unable to perform walk test (baseline n=83). OUTCOMES: Survival; hospitalization; activities of daily living (ADL) difficulty; 36-Item Short Form Health Survey (SF-36) Physical Function score. MEASUREMENTS: Cox proportional hazards models investigated gait speed and mortality over a median follow-up of 703 days. Multivariable logistic or linear regression models estimated associations of baseline gait speed with hospitalization, need for ADL assistance, and SF-36 Physical Function score after 12 months. RESULTS: Participants who walked ≥0.6 m/s had 53 (9%) deaths, those who walked <0.6 m/s had 19 (20%) deaths, and those unable to walk had 37 (44%) deaths. Adjusted mortality hazard ratios were 2.17 (95% CI, 1.19-3.98) for participants who walked <0.6 m/s and 6.93 (95% CI, 4.01-11.96) for those unable to walk, compared with participants walking ≥0.6 m/s. After 12 months, compared with baseline walk speed ≥ 1.0 m/s (n=169 participants), baseline walk speed of 0.6 to <0.8 m/s (n=116) was associated with increased odds of hospitalization (OR, 2.04; 95% CI, 1.19-3.49) and ADL difficulty (OR, 3.88; 95% CI, 1.46-10.33) and a -8.20 (95% CI, -13.57 to -2.82) estimated change in SF-36 Physical Function score. LIMITATIONS: Cohort not highly representative of overall US in-center HD population. CONCLUSIONS: Because walking challenges the heart, lungs, and circulatory, nervous, and musculoskeletal systems, gait speed provides an informative marker of health status. The association of gait speed with HD patients' risk for functional decline warrants continued study.

Characterization of physical activity and sitting time among patients on hemodialysis using a new physical activity instrument.

OBJECTIVES: Physical activity questionnaires usually focus on moderate to vigorous activities and may not accurately capture physical activity or variation in levels of activity among extremely inactive groups like dialysis patients. DESIGN: Cross-sectional study. SETTING: Three dialysis facilities in the San Francisco Bay Area. SUBJECTS: Sixty-eight prevalent hemodialysis patients. INTERVENTION: We administered a new physical activity questionnaire designed to capture activity in the lower end of the range, the Low Physical Activity Questionnaire (LoPAQ). MAIN OUTCOME MEASURE: Outcome measures were correlation with a validated physical activity questionnaire, the Minnesota Leisure Time Activity (LTA) questionnaire and with self-reported physical function (physical function score of the SF-36) and physical performance (gait speed, chair stand, balance, and short physical performance battery). We also determined whether patients who were frail or reported limitations in activities of daily living were less active on the LoPAQ. RESULTS: Sixty-eight participants (mean age 59 ± 14 years, 59% men) completed the study. Patients were inactive according to the LoPAQ, with a median (interquartile range) of 517 (204-1190) kcal/week of physical activity. Although activity from the LTA was lower than on the LoPAQ (411 [61-902] kcal/week), the difference was not statistically significant (P = .20), and results from the 2 instruments were strongly correlated (rho = 0.62, P < .001). In addition, higher physical activity measured by the LoPAQ was correlated with better self-reported functioning (rho = 0.64, P < .001), better performance on gait speed (rho = 0.32, P = .02), balance (rho = 0.45, P < .001), and chair rising (rho = -0.32, P = .03) tests and with higher short physical performance battery total score (rho = 0.51, P < .001). Frail patients and patients with activities of daily living limitations were less active than those who were not frail or limited. CONCLUSIONS: The LoPAQ performed similarly to the Minnesota LTA questionnaire in our cohort despite being shorter and easier to administer.

Low Physical Function in Maintenance Hemodialysis Patients Is Independent of Muscle Mass and Comorbidity.

OBJECTIVES: It is unknown whether muscle wasting accounts for impaired physical function in adults on maintenance hemodialysis (MHD). DESIGN: Observational study. SETTING: Outpatient dialysis units and a fall clinic. SUBJECTS: One hundred eight MHD and 122 elderly nonhemodialysis (non-HD) participants. EXPOSURE VARIABLE: Mid-thigh muscle area was measured by magnetic resonance imaging. MAIN OUTCOME MEASURE: Physical function was measured by distance walked in 6 minutes. RESULTS: Compared with non-HD elderly participants, MHD participants were younger (49.2 ± 15.8 vs. 75.3 ± 7.1 years; P < .001) and had higher mid-thigh muscle area (106.2 ± 26.8 vs. 96.1 ± 21.1 cm2; P = .002). However, the distance walked in 6 minutes was lower in MHD participants (322.9 ± 110.4 vs. 409.0 ± 128.3 m; P < .001). In multiple regression analysis adjusted for demographics, comorbid conditions, and mid-thigh muscle area, MHD patients walked significantly less distance (-117 m; 95% confidence interval: -177 to -56 m; P < .001) than the non-HD elderly. CONCLUSIONS: Even when compared with elderly non-HD participants, younger MHD participants have poorer physical function that was not explained by muscle mass or comorbid conditions. We speculate that the uremic milieu may impair muscle function independent of muscle mass. The mechanism of impaired muscle function in uremia needs to be established in future studies.

The BASES expert statement on exercise therapy for people with chronic kidney disease.

Chronic kidney disease (CKD) is becoming a serious health problem throughout the world and is one of the most potent known risk factors for cardiovascular disease, which is the leading cause of morbidity and mortality in this patient population. Physical inactivity has emerged as a significant and independent risk factor for accelerated deterioration of kidney function, physical function, cardiovascular function and quality of life in people in all stages of CKD. CKD specific research evidence, combined with the strong evidence on the multiple health benefits of regular and adequate amounts of PA in other cardiometabolic conditions, has resulted in physical inactivity being identified by national and international CKD clinical practice guidelines as one of the multiple risk factors that require simultaneous and early intervention for optimum prevention/management of CKD. Despite this realisation, physical inactivity is not systematically addressed by renal care teams. The purpose of this expert statement is therefore to inform exercise and renal care specialists about the clinical value of exercise therapy in CKD, as well as to provide some practical recommendations on how to more effectively translate the existing evidence into effective clinical practice.

Physical function and physical activity assessment and promotion in the hemodialysis clinic: a qualitative study.

BACKGROUND: Despite practice guidelines (KDOQI [Kidney Disease Outcomes Quality Initiative]) recommending regular assessment of physical function and encouragement of physical activity, few clinics in the United States objectively assess physical function/physical activity or provide recommendations for physical activity in their patient care. STUDY DESIGN: Qualitative methods were used to develop an understanding of practice patterns related to physical function assessment and physical activity encouragement by dialysis staff. SETTING & PARTICIPANTS: Data were collected in one outpatient university-based hemodialysis clinic. 15 patient care staff were interviewed and 6 patients were observed. METHODOLOGY: Semistructured interviews of patient care staff were conducted, along with nonparticipant observations of the clinic environment and operations and review of archival materials. ANALYTIC APPROACH: Coding of the interviews was descriptive, followed by interpretive coding by the research team. On-site field notes were transcribed for analysis. RESULTS: There was universal unawareness of the KDOQI guideline related to physical function/physical activity; however, all staff thought their patients would benefit from physical activity. There were no objective assessments of physical function and no resources or training to facilitate physical activity encouragement. Staff described deteriorating physical function in their patients, which was frustrating and disappointing. Barriers to physical activity included clinical/disease factors, staff "overaccommodation," and a system of dialysis care that facilitates sedentary behavior and does not require or incentivize clinics to promote physical activity. The patient care technicians were interested and thought that they had time to promote physical activity, but thought that they were unprepared to do so, indicating a need for education and training and a need to develop protocols to address the issue as routine practice. LIMITATIONS: This was a single university-based center; however, because hemodialysis procedures are prescribed by Centers for Medicare & Medicaid Services regulations, it is likely that practice in this clinic is representative of nationwide practice. CONCLUSIONS: Development of strategies to implement practice change that addresses low physical function and physical activity is warranted.

Association of physical function with predialysis blood pressure in patients on hemodialysis.

BACKGROUND: New information from various clinical settings suggests that tight blood pressure control may not reduce mortality and may be associated with more side effects. METHODS: We performed cross-sectional multivariable ordered logistic regression to examine the association between predialysis blood pressure and the short physical performance battery (SPPB) in a cohort of 749 prevalent hemodialysis patients in the San Francisco and Atlanta areas recruited from July 2009 to August 2011 to study the relationship between systolic blood pressure and objective measures of physical function. Mean blood pressure for three hemodialysis sessions was analyzed in the following categories: <110 mmHg, 110-129 mmHg (reference), 130-159 mmHg, and ≥160 mmHg. SPPB includes three components: timed repeated chair stands, timed 15-ft walk, and balance tests. SPPB was categorized into ordinal groups (≤6, 7-9, 10-12) based on prior literature. RESULTS: Patients with blood pressure 130-159 mmHg had lower odds (OR 0.57, 95% CI 0.35-0.93) of scoring in a lower SPPB category than those whose blood pressure was between 110 and 129 mmHg, while those with blood pressure≥160 mmHg had 0.56 times odds (95% CI 0.33-0.94) of scoring in a lower category when compared with blood pressure 110-129 mmHg. When individual components were examined, blood pressure was significantly associated with chair stand (130-159 mmHg: OR 0.59, 95% CI 0.38-0.92) and gait speed (≥160 mmHg: OR 0.59, 95% CI 0.35-0.98). Blood pressure≥160 mmHg was not associated with substantially higher SPPB score compared with 130-159 mmHg. CONCLUSIONS: Patients with systolic blood pressure at or above 130 mmHg had better physical performance than patients with lower blood pressure in the normotensive range. The risk-benefit tradeoff of aggressive blood pressure control, particularly in low-functioning patients, should be reexamined.

The association of physical activity and physical function with clinical outcomes in adults with chronic kidney disease.

PURPOSE OF REVIEW: Despite guidelines supporting the regular assessment of physical functioning and encouragement of physical activity in management of the patient with chronic kidney disease (CKD), implementation has been undermined by a lack of understanding of the evidence for this recommendation. The purpose of this review is to present a summary of emerging data from larger epidemiologic cohorts that report associations between low levels of physical functioning and/or low physical activity and clinical outcomes in patients with CKD. RECENT FINDINGS: Low levels of physical activity and poor physical functioning are strongly associated with mortality and poor clinical outcomes in adult patients with CKD, regardless of treatment modality. Low physical performance and activity limitations are more prevalent in patients with CKD, regardless of age, compared to older community-dwelling adults. SUMMARY: The strength of the evidence presented should strongly motivate a focus of treatment on assessing and improving physical activity and physical function as part of routine patient-centered management of persons with CKD. Physical activity interventions are warranted because patients with CKD, regardless of age, have a high prevalence of low physical functioning and frailty that is similar to or higher than the general population of elderly adults; physical activity, physical function, and performance are strongly associated with all-cause mortality; and exercise training and exercise counseling have been shown to improve measures of physical functioning.

Effects of the left ventricular assist device on the compliance and distensibility of the carotid artery.

We investigated the impact of continuous-flow left ventricular assist devices (LVAD) on the carotid elastic properties. Carotid artery parameters (diameter distensibility (DD), cross-sectional distensibility (CSD), diameter compliance (DC), cross-sectional compliance (CSC), and incremental elastic modulus (IEM)) were measured in a cross-sectional study using a standard ultrasound with a 10-MHz linear array probe. Measurements (mean ± SEM) were made in separate groups at various clinical time points: prior to LVAD surgery (baseline; 13 male/3 female; age 48 ± 3 years), 1 week following LVAD placement (acute; 12 male/2 female; age 47 ± 3 years), approximately 24 weeks following LVAD surgery (chronic; 13 male/2 female; age 52 ± 3 years), and in a group of healthy subjects (controls; 9 male/1 female; age 51 ± 4 years). Distensibility properties were lower (P < 0.05) in the acute (DD 2.3 % ± 0.4 %; CSD 4.7 % ± 0.8 %) and chronic (DD 2.2 % ± 0.4 %; CSD 4.5 ± 0.9 %) compared with the baseline (DD 5.9 % ± 0.7 %; CSD 12.2 % ± 1.5 %) and control (DD 5.8 % ± 0.6 %; CSD 11.9 % ± 1.3 %) groups. Compliance properties were lower (P < 0.05) in the chronic (DC 4.4 ± 0.7 mm/mmHg × 10(-3); CSC 1.2 ± 0.2 mmHg(-1) × 10(-3)) compared with acute (DC 9.0 ± 1.6 mm/mmHg × 10(-3); CSC 2.6 ± 0.4 mmHg(-1) × 10(-3)) and baseline (DC 11.1 ± 1.1 mm/mmHg × 10(-3); CSC 3.3 ± 0.4 mmHg(-1) × 10(-3)) groups. The compliance properties in the control (DC 8.3 ± 0.8 mm/mmHg × 10(-3); CSC 2.4 ± 0.2 mmHg(-1) × 10(-3)) group were not different from any of the patient groups. The IEM was higher (P < 0.05) in the chronic (6908 ± 1269 mmHg) compared with acute (2739 ± 412 mmHg), baseline (1849 ± 177 mmHg), and control (2349 ± 241 mmHg) groups. Chronic continuous-flow LVAD support is associated with lower carotid artery compliance and distensibility, which may place further strain on the left ventricle.

Physical function and gait speed in patients with chronic kidney disease.

Patients with chronic kidney disease (CKD) who are treated with dialysis have impaired physical functioning that is associated with poor outcomes. Gait speed is an important measure of mobility that predicts adverse events and mortality in older people. Gait speed is low in patients with CKD, and those treated with hemodialysis average below cut-points known to indicate increased risk of reduced survival and adverse health events. Measurement of gait speed in patients with CKD may be valuable in identifying those at risk for adverse events, including disability and mortality.

Exercise in individuals with CKD.

There are few studies evaluating exercise in the nondialysis chronic kidney disease (CKD) population. This review covers the rationale for exercise in patients with CKD not requiring dialysis and the effects of exercise training on physical functioning, progression of kidney disease, and cardiovascular risk factors. In addition, we address the issue of the risk of exercise and make recommendations for implementation of exercise in this population. Evidence from uncontrolled studies and small randomized controlled trials shows that exercise training results in improved physical performance and functioning in patients with CKD. In addition, although there are no studies examining cardiovascular outcomes, several studies suggest that cardiovascular risk factors such as hypertension, inflammation, and oxidative stress may be improved with exercise training in this population. Although the current literature does not allow for definitive conclusions about whether exercise training slows the progression of kidney disease, no study has reported worsening of kidney function as a result of exercise training. In the absence of guidelines specific to the CKD population, recent guidelines developed for older individuals and patients with chronic disease should be applied to the CKD population. In sum, exercise appears to be safe in this patient population if begun at moderate intensity and increased gradually. The evidence suggests that the risk of remaining inactive is higher. Patients should be advised to increase their physical activity when possible and be referred to physical therapy or cardiac rehabilitation programs when appropriate.

Effects of modality change and transplant on peak oxygen uptake in patients with kidney failure.

BACKGROUND: Exercise capacity as measured by peak oxygen uptake (Vo2(peak)) is low in hemodialysis patients. The present study assesses determinants of VO2(peak) in patients with chronic kidney failure who either changed kidney replacement modality to frequent hemodialysis therapy or received a kidney transplant. STUDY DESIGN: Cohort study with assessment at baseline and 6 months after modality change. SETTING & PARTICIPANTS: Participants included nondiabetic individuals receiving conventional hemodialysis who: (1) remained on conventional hemodialysis therapy (n = 13), (2) changed to short daily hemodialysis therapy (n = 10), or (3) received a transplant (n = 5) and (4) individuals who underwent a pre-emptive transplant (n = 15). Additionally, 34 healthy controls were assessed at baseline only. PREDICTOR: Modality change. MEASUREMENT & OUTCOMES: Exercise capacity, assessed using the physiologic components of the Fick equation (Vo2 = cardiac output × a-vo2(dif), where a-vo2(dif) is arterial to venous oxygen difference) was determined using measurement of Vo2(peak) and cardiac output during symptom-limited exercise testing. Analysis of covariance was used to compare differences in changes in Vo2(peak), cardiac output, heart rate, stroke volume, and a-vo2(dif) at peak exercise between participants who remained on hemodialysis therapy and those who underwent transplant. RESULTS: Transplant was the only modality change associated with a significant change in Vo2(peak), occurring as a result of increased peak cardiac output and reflecting increased heart rate without a change in peak a-vo2(dif) despite increased hemoglobin levels. There were no differences in participants who changed to daily hemodialysis therapy compared with those who remained on conventional hemodialysis therapy. LIMITATIONS: Small nonrandomized study. CONCLUSIONS: Vo2(peak) increases significantly after kidney transplant, but not with daily hemodialysis; this improvement reflects increased peak cardiac output through increased peak heart rate. Despite statistical significance, the increase in Vo2(peak) was not clinically significant, suggesting the need for interventions such as exercise training to increase Vo2(peak) in all patients regardless of treatment modality.

Baseline physical performance, health, and functioning of participants in the Frequent Hemodialysis Network (FHN) trial.

BACKGROUND: Self-reported physical health and functioning and direct measures of physical performance are decreased in hemodialysis patients and are associated with mortality and hospitalization. STUDY DESIGN: We determined baseline cross-sectional associations of physical performance, health, and functioning with demographics, clinical characteristics, nutritional indexes, laboratory benchmarks, and measures of body composition in participants in the Frequent Hemodialysis Network (FHN) trial. SETTING & PARTICIPANTS: 375 persons enrolled in the FHN with data for physical performance, health, and functioning. PREDICTORS: Explanatory variables were categorized into fixed factors of age, race, comorbid conditions (diabetes mellitus, heart failure, and peripheral arterial disease) and potentially modifiable factors of dialysis dose, phosphorus level, hemoglobin level, equilibrated normalized protein catabolic rate (enPCR), body composition, body mass index, phase angle, and ratio of intracellular water volume to body weight (calculated from bioelectrical impedance). OUTCOMES: Scores on tests of physical performance, health, and functioning. MEASUREMENTS: Physical performance measured using the Short Physical Performance Battery, self-reported physical health and functioning using the 36-Item Short Form Health Survey (SF-36). Body composition (body mass index and bioimpedance analysis) and laboratory data were obtained from affiliated dialysis providers. RESULTS: Relative to population norms, scores for all 3 physicality metrics were low. Poorer scores on all 3 metrics were associated with diabetes mellitus and peripheral arterial disease. Poorer scores on the SF-36 Physical Functioning subscale and Short Physical Performance Battery also were associated with age, lower ratio of intracellular water volume to body weight, and lower enPCR. Black race was associated with poorer scores on the Short Physical Performance Battery. LIMITATIONS: This was a cross-sectional study of individuals agreeing to participate in the FHN study and may not be generalizable to the general dialysis population. CONCLUSIONS: Hemodialysis patients show markedly impaired physical performance, health, and functioning relative to population norms. Although some factors associated with these impairments are not modifiable, others may change with improvement in nutritional status or body composition.

Self-reported physical activity in patients with end stage renal disease.

Patients served by ESRD Network 11 were surveyed on participation in regular physical activity (physical activity). National recommendations (3 days/week, 30 minutes/session, and intensity of "moderate level") were used to categorize respondents into three physical activity categories: no physical activity, some physical activity, and recommended levels of physical activity. Analysis of 1323 returned questionnaires indicated that 57% of respondents reported participation in regular physical activity; however, only 13.2% achieved recommended levels based on frequency, duration, and intensity. The primary reasons for no physical activity were '"too tired" and "not motivated." The most frequently cited benefits in those who reported regular physical activity were "increased energy," "increased muscle strength," and "enhanced ability to do things needed in life." Fifty-seven percent reported they had "been talked to about exercise;" only 34% received any written information on initiating physical activity. Greater effort to incorporate education and motivation into the routine care is warranted to increase physical activity to levels that may result in health benefits.

Health-related fitness and physical activity in patients with nonalcoholic fatty liver disease.

UNLABELLED: Nonalcoholic fatty liver disease (NAFLD) has been referred to as the hepatic manifestation of the metabolic syndrome. There is a lower prevalence of metabolic syndrome in individuals with higher health-related fitness (HRF) and physical activity (PA) participation. The relationship between NAFLD severity and HRF or PA is unknown. Our aim was to compare measures of HRF and PA in patients with a histological spectrum of NAFLD severity. Thirty-seven patients with liver biopsy-confirmed NAFLD (18 women/19 men; age = 45.9 +/- 12.7 years) completed assessment of cardiorespiratory fitness (CRF, VO(2peak)), muscle strength (quadriceps peak torque), body composition (%fat), and PA (current and historical questionnaire). Liver histology was used to classify severity by steatosis (mild, moderate, severe), fibrosis stage (stage 1 versus stage 2/3), necroinflammatory activity (NAFLD Activity Score; or=5 NAS2) and diagnosis of NASH by Brunt criteria (NASH versus NotNASH). Analysis of variance and independent t tests were used to determine the differences among groups. Fewer than 20% of patients met recommended guidelines for PA, and 97.3% were classified at increased risk of morbidity and mortality by %fat. No differences were detected in VO(2peak) (x = 26.8 +/- 7.4 mL/g/min) or %fat (x = 38.6 +/- 8.2%) among the steatosis or fibrosis groups. Peak VO(2) was significantly higher in NAS1 versus NAS2 (30.4 +/- 8.2 versus 24.4 +/- 5.7 mL/kg/min, P = 0.013) and NotNASH versus NASH (34.0 +/- 9.5 versus 25.1 +/- 5.7 mL/kg/min, P = 0.048). CONCLUSION: Patients with NAFLD of differing histological severity have suboptimal HRF. Lifestyle interventions to improve HRF and PA may be beneficial in reducing the associated risk factors and preventing progression of NAFLD.

Physical Function and Physical Activity in Peritoneal Dialysis Patients.

BACKGROUND: Physical functioning (PF) and physical activity (PA) are low in patients treated with maintenance hemodialysis (MHD). Little information exists on this topic in patients treated with peritoneal dialysis (PD). The objective of this study was to compare PF and PA in patients with Stage-5 chronic kidney disease (CKD) treated with PD and in-center MHD. METHODS: Physical functioning was measured in 45 prevalent PD patients using standard physical performance measures that include gait speed, chair stand, standing balance, 6-minute-walk, incremental shuttle walk and self-reported PF using the short form (SF)-36 questionnaire. Physical activity was determined from self-report and using the Community Healthy Activities Model Program for Seniors (CHAMPS) questionnaire. Scores for the short physical performance battery (SPPB) were calculated. In-center MHD patients were matched by age, gender, and diabetes status to the PD patients. RESULTS: Unadjusted comparisons showed significantly higher 6-minute-walk distance, shuttle-walk distance and hand-grip in the PD patients. Adjustment in multiple regression analysis resulted in only gait speed being significantly different between the groups. All test results in both groups were lower than reference values for age and gender in the general population, and were at the levels indicating impairment. Physical activity was not different between the 2 groups (average age 49 yrs), and both groups had weekly caloric expenditure from all exercise and from moderate-intensity exercise that was similar to older (> 70 yrs) community-dwelling adults. Adjusted association indicated that PA was significantly associated with shuttle-walk distance. CONCLUSIONS: Physical functioning and PA measures were low in both PD and MHD groups. Interventions to improve PA and PF should be strongly considered for both PD and MHD patients.

The comprehensive assessment of physical fitness in children following kidney and liver transplantation.

BACKGROUND: Pediatric organ transplant recipients may have elevated cardiovascular (CV) risk. Low cardiorespiratory fitness (CRF) may contribute to CV risk; however, studies of CRF in children following kidney transplantation (KTx) and liver transplantation (LTx) are limited. METHODS: Laboratory testing included assessment of CRF (VO2peak), muscle strength, and body composition (%fat). Field testing (FITNESSGRAM) included the PACER, curl-up, and sit-and-reach tests. Values obtained were compared to sex- and age-based criterion-referenced standards (Healthy Fitness Zone, HFZ). The Previous Day Physical Activity Recall was used to assess after-school physical activity (PA) participation. Independent t tests were used to compare groups. RESULTS: Twenty-five KTx and 11 LTx recipients were tested. The groups were similar in all measures. Both groups demonstrated below normative values for VO2peak and muscle strength. Only 4% of the KTx and 9% of the LTx recipients achieved the HFZ for the PACER and 24% of the KTx and 45% of the LTx attained the HFZ for the curl-up test. Approximately 44% of both groups had percent fat greater than the upper criterion value of the HFZ. Both groups reported spending only 8% of their after-school time participating in physical activity. CONCLUSIONS: Pediatric KTx and LTx recipients have significantly reduced CRF, muscle strength, and physical activity. Routine counseling and encouragement for increased physical activity is recommended as a part of routine care. A randomized clinical exercise intervention trial after pediatric solid organ transplantation is warranted to determine the impact of such lifestyle intervention on improving physical fitness and cardiovascular health.

Physical functioning in end-stage renal disease patients: update 2005.

Physical functioning in patients with end-stage renal disease treated with dialysis is low, whether measured using objective laboratory measures, physical performance testing, or self-reported measures. Peak oxygen uptake (VO2peak), self-reported functioning measures, and physical activity levels are independent predictors of mortality in these patients. Cardiovascular exercise training studies result in improvements in VO2peak, physical performance tests, and self-reported functioning. Resistance exercise training improves muscle strength. Exercise training may have positive benefits on other factors that are important clinical issues in dialysis patients, including cardiovascular risk profile, oxidative stress, and inflammation. Endothelial function, a surrogate marker of atherosclerosis, has been shown to improve with exercise training in dialysis patients. Although there have been numerous recent studies on benefits of exercise, few dialysis clinics or nephrologists provide encouragement or programs as a part of their routine care of their patients. There are many national guidelines that include exercise or increasing physical activity as a part of the treatment of many conditions that are relevant in dialysis patients, including hypertension, hyperlipidemia, and high cardiovascular disease risk. The nephrology community continues to state concern for outcomes; however, a simple, low-tech intervention that has many benefits to their patients (i.e., encouragement, recommendations, and opportunity for increasing physical activity) has not been adopted as part of the standard care. Adoption of routine counseling and encouragement for physical activity has the potential to improve outcomes, improve physical functioning, and optimize quality of life and overall health of dialysis patients.

A randomized trial of exercise training after renal transplantation.

BACKGROUND: Significant health benefits result from regular physical activity, many which are important for transplant recipients. Although exercise capacity improves initially after transplant, it is not normalized, and only two studies have reported the effects of exercise training in this population. We report a randomized clinical trial of exercise after renal transplantation (RTX). METHODS: One hundred sixty-seven patients were randomized at 1 month after RTX into two groups: exercise intervention (EX) and usual care (UC), with repeat testing at 6 and 12 months. Ninety-five patients completed the following testing at both testing times: symptom-limited treadmill testing with measurement of peak oxygen uptake (peak Vo2); isokinetic muscle testing for muscle strength; and dual-energy X-ray absorptiometry scans for body composition. The SF-36 Health Status Questionnaire assessed self-reported functioning. The exercise intervention consisted of individually prescribed programs to be conducted at home with regular phone follow-up to enhance adherence. Repeated measures analysis of variance was performed to determine differences between the groups for the three testing times. RESULTS: At 1 year 67% of the EX group were exercising regularly compared with 36% of the UC group (P=0.01). Compared with the UC group, the EX group had significantly greater gains in peak Vo2 (P=0.016), percent age-predicted Vo2 (P=0.03), and muscle strength (P=0.05), and a trend toward higher self-reported physical functioning (P=0.06). There were no differences between the groups in changes in body composition. At 1 year, peak Vo2 was significantly correlated with age, percent fat, muscle strength, hematocrit, and self-reported physical functioning. CONCLUSIONS: Exercise training after RTX results in higher levels of measured and self-reported physical functioning; however, exercise alone does not affect body composition.