Wednesday, 27 May 2009

Exercise training in chronic kidney disease

As my annual cycling trip looms before me, my thoughts if not my legs, have turned to exercise regimes again and I have spent a little time reading and discussing the subject. Many people with advanced kidney disease complain of tiring easily, difficulty climbing stairs, rising from a squatting position and muscle fatigue after minor physical activity. We also know that as kidney disease progresses maximal exercise capacity falls – to about 50% of the expected muscle strength on dialysis. In the old days, renal anaemia was thought to be the main cause of this muscle weakness. Treatment of renal anaemia improves but doesn’t correct the physical exercise capacity and we now know that there is abnormal muscle energy metabolism in CKD. This is compounded by the effects of physical inactivity. People who have received kidney transplants also have problems sometimes related to the use of steroids as part of their antirejection treatment.

During the last 30 years an increasing number of studies have been published showing positive effects of different exercise training programmes on muscular strength and endurance and functional capacity such as walking distance and quality-of-life in patients with chronic kidney disease. Therefore it’s a surprise that most kidney specialists and teams do not offer physical exercise training programmes. My impression is that most kidney doctors, nurses and dietitians do endorse exercise as part of healthy living but don’t provide other support or guidance. “How much exercise is it safe for me to do Doc?“ is not the sort of question we find easy to answer and for instance some gyms actively discourage those with raised blood pressure or on antihypertensive drugs!! The advice to consult your physician that’s on the side of exercise bikes and other equipment might absolve the company of responsibility but will only rarely result in a personalised exercise plan or prescription from your doctor. A few units do offer the option of exercise on dialysis but that hasn’t really taken off. Perhaps that’s because of the uncertainty of what we should be offering. The various studies that have been reported used a wide range of approaches. Therefore I was very pleased when I recently looked into the subject to find that researchers from the Karolinska Institute in Stockholm, Sweden are conducting a Cochrane review to provide evidence on how exercise training programme at various stages of kidney disease should be constructed. It should identify the type of exercises, duration, intensity and frequency that are needed to be able to affect certain outcomes.

Having the scientific evidence of what works will be the first step in develop exercise programmes for people with CKD, fostering the culture within our kidney services so that exercise has a higher profile and supporting the behaviorial change so that individuals optimise their own exercise capacity is a bigger challenge. The rewards are likely to be great .

Talking of exercise, are you keeping up with Tony Ward's progress – you can read Tony’s blog on NHS Choices. If I survive this years trip, to the Col de Tourmaline, then I will definitely train for next years – my sons have the Marmot pencilled in!!!