Exerciseand CKDCurrent Recommendations

Exercise and Chronic Kidney Disease
Current Recommendations
Michael Bruneau Jr. MS, ACSM EPC, NASM CPT
Springfield College, Springfield, MA
May 4th, 2016
Overview
• Staging of CKD
• Prevalence of CKD
• Consequences of having CKD
• PA and mortality in CKD
• Exercise and CKD in predialysis patients
• Exercise and the progression of CKD
• Exercise and CVD in CKD
• Exercise and physical function in CKD
• Current recommendations
STAGING OF CKD
Staging of CKD
• Chronic kidney disease is defined as either
damage or a glomerular filtration rate < 60
mL/min/1.73m2 for ≧ 3 months
• Kidney damage is defined as pathologic
abnormalities or markers of damage, including
abnormalities in blood or urine or imaging
studies
KDOQI Guidelines (2005)

Staging of CKD (K/DOQI)
Stage Description GFR (mL/min/1.73m2)

1 Kidney damage with normal GFR ≧90
2 Kidney damage with mild ↓ GFR 60-89
3 Moderate ↓GFR 30-59
4 Severe ↓GFR 15-29
5 Kidney failure < 15 or dialysis
Treatments for ESRD
• Patient with ESRD have FOUR treatment
options:
– Hemodialysis (in center and home)
– Peritoneal dialysis (home)
– Kidney transplantation
– “Conservative management”
• No dialysis or transplant option often chosen by
frail elderly patients
PREVALENCE OF CKD
Prevalence of CKD
• 25 million people (~13.4%) in the United
States (US) have CKD
– Based upon estimates using albumin/creatinine
ratios (ACR), and GFR values
• Affects > 40% of people > 70 years of age
Levey et al. (2010)

Prevalence (%) of CKD in the NHANES
population within age, gender, race/ethnicity,
and risk factor categories
NHANES 1988–1994 & 2005–2010 participants age 20 & older;

single-sample estimates of eGFR & ACR. eGFR calculated using the
CKD-EPI equation.
Projected growth of prevalent dialysis and
transplant populations Figure 2.2 (Volume 2)
Counts projected using

a Markov model.
Original projections
used data through 2000;
new projections use
data through 2006.
CONSEQUENCES OF HAVING CKD
Life expectancy of NHANES participants
with or without CKD, 1999–2004
Figure 1.16 (Volume 1)
NHANES 1999–2004 participants age 20 & older; single sample estimates of eGFR
& ACR. eGFR calculated using the CKD-EPI equation.
Adjusted hospitalization rates (per 1,000
patient years) in Medicare patients, by CKD
diagnosis code, 2011
January 1, 2011 point prevalent Medicare patients, age 66 & older on December
31, 2010. Adj: age/gender/race/prior hospitalization/comorbidity; rates by one
factor are adjusted for the others. Ref: Medicare patients age 66 & older, 2011.
Per person per year expenditures for CKD in
the Medicare population age 65 yrs and
older, by at-risk group Figure 7.8 (Volume 1)
Point prevalent Medicare CKD patients age 65 & older. Includes Part D.
The Bottom Line
• CKD is a costly disease and its prevalence is
increasing
• CKD patients are at greater risk of dying
prematurely than progressing to ESRD
• Preliminary evidence has shown increased
fitness and physical activity levels may be
protective in CKD
PHYSICAL ACTIVITY AND
MORTALITY IN CKD
Physical Activity and Mortality in CKD
(NHANES III)
Patients followed for 7 years

• 15% of sample inactive
• 43% of sample insufficiently active
• 42% of sample met recommended levels of PA
Exercise Capacity as a Predictor of Survival Among Ambulatory Patients with End-stage
Renal Disease
The Bottom Line
• CKD is associated with reduced PA
• LTPA is associated with decreased

mortality in CKD
• VO2peak is a strong predictor of

survival
EXERCISE AND CKD IN PREDIALYSIS
PATIENTS
Exercise and CKD
• People living with CKD
often have exertional
fatigue
• Precise cause is
unknown but is
believed to be due to
issues with oxygen
delivery rather than
oxygen utilization
Macdonald et al. (2012)

Exercise and CKD
• People with CKD have been shown to have
peak oxygen uptake values that average 50-
80% of normal age matched controls
• Limited data available on the effect of exercise
for patients living with predialysis
• Studies have shown improvements in oxygen
uptake similar to those living with ESRD
Johansen & Painter (2012)

The Bottom Line
• Exercise training does NOT worsen kidney
function in CKD patients
• Resistance exercise improves muscle mass,
physical function and counteracts catabolism
of low protein diets and uremia with renal
failure
EXERCISE AND THE PROGRESSION
OF CKD
Exercise and the Progression of CKD
• Kidney function normally declines at the rate

of 1 mL/min/year
• In those with CKD, secondary to diabetes, the
rate of decline can exceed 10mL/min/year
• It has been well established that good blood
pressure control in addition to the use of ACE
inhibitors reduces the rate of decline
Jaber & Madias (2005)

Exercise and the Progression of CKD
• There is some evidence from animal studies

that exercise training can modify kidney
function in CKD
• There have been a few published studies
with mixed results involving humans that
have investigated the impact of exercise
training on the progression of CKD
The Bottom Line
• Aerobic exercise training appears to improve
VO2peak and heart rate values in predialysis
patients
• Higher amounts of habitual physical activity
associate with a slower GFR decline among
patients with CKD
EXERCISE AND CVD IN CKD
Prevalence of CKD
• Researchers have noted that there are > 16
million stage 3 or 4 CKD patients
• But only ~ 400,000 dialysis patients
• Why is there this big gap between the
numbers of CKD patients in stage 3 or 4 of the
disease and those who “progress” to ESRD?
Beddhu et al. (2009)

CKD and CVD
• Most CKD patients do NOT progress from
earlier stages of the disease to ESRD; rather,
most die prematurely of CVD
• Believed to be due to the presence of
traditional CVD risk factors and other risk
factors
– Traditional: HTN, dyslipidemia, diabetes
– Other: endothelial dysfunction, SNS activity,
oxidative stress, inflammation
Johansen & Painter (2011)

CKD and Arterial Stiffness
• Clear evidence demonstrates that people with
CKD have stiffer arteries, linked to:
– LVH
– CHF
– Strokes
– MI
• Arterial stiffness is considered an
independent risk factor for CVD
Greenwald (2007), Maeda et al. (2005), Otsuki et al. (2007)

Exercise and Arterial Stiffness
• Numerous researchers have reported aerobic
exercise to beneficially reduce arterial stiffness
in clinical and non-clinical populations
• However, no one has ever investigated the
effect or aerobic exercise on arterial stiffness
in a group of CKD patients
EXERCISE AND PHYSICAL
FUNCTION IN CKD
CKD and Physical Function
• People living with CKD demonstrate marked impairment
in aerobic capacity, physical function, and lower habitual
levels of physical activity compared to healthy controls
• People with CKD and ESRD therefore exhibit higher rates
of
– Lower extremity dysfunction
– Sarcopenia
– Slower gait speed
– Physical inactivity
– Higher rates of fatigue and exhaustion
Weiner & Seliger (2014)

The Bottom Line
• Medically stable patients living with CKD and
ESRD should be encouraged to participate in
moderately intense resistance exercise
– It is safe
– It can lead to substantial improvements in
function
Headley et al. (2012)

CURRENT RECOMMENDATIONS
ACSM FITT ExRx for
Chronic Kidney Disease
Conclusions
• CKD is a major and costly public health issue in the US
• Aerobic and resistance exercise may be used as a non-
pharmacological lifestyle therapy to treat and control
CKD
• Exercise does not worse kidney function and improves
cardiorespiratory, muscular, and functional parameters
of health
• Because exercise has been deemed to be both safe and
efficacious, the routine prescription of exercise should
be made to those living with CKD
Thank You
mbruneaujr@springfieldcollege.edu
@bruneaumil
References
• Beddhu, S., Baird, B. C., Zitterkoph, J., Neilson, J., & Greene, T. (2009). Physical activity and mortality in
chronic kidney disease (NHANES III). Clinical journal of the American Society of Nephrology : CJASN,
4(12), 1901–1906. doi:10.2215/CJN.01970309
• Boyce, M. L., Robergs, R. A., Avasthi, P. S., Roldan, C., Foster, A., Montner, P., … Nelson, C. (1997).
Exercise training by individuals with predialysis renal failure: cardiorespiratory endurance,
hypertension, and renal function. American Journal Of Kidney Diseases: The Official Journal Of The
National Kidney Foundation, 30(2), 180–192. Retrieved from http://ezproxy.spfldcol.edu/login?
url=http://search.ebscohost.com/login.aspx?
direct=true&db=cmedm&AN=9261028&loginpage=login.asp&site=ehost-live
• Castandeda, C., Gordon, P. L., Uhlin, K. L., Levey, A. S., Kehayias, J. J., Dwyer, J. T., … Singh, M. F. (2001).
Resistance training to counteract the catabolism of a low-protein diet in patients with chronic renal
insufficiency. Ann Intern Med, 135(11), 965–976.
• Diesel, W., Noakes, T. D., Swanepoel, C., & Lambert, M. (1990). Isokinetic muscle strength predicts
maximum exercise tolerance in renal patients on chronic hemodialysis. American Journal Of Kidney
Diseases: The Official Journal Of The National Kidney Foundation, 16(2 (Print)), 109–114. Retrieved from
http://ezproxy.spfldcol.edu/login?url=http://search.epnet.com/login.aspx?
direct=true&db=cmedm&an=2382645&loginpage=login.asp
• Eidemak, I., Haaber, A. B., Feldt-Rasmussen, B., Kanstrup, I.-L., & Strandgaard, S. (1997). Exercise
Training and the Progession of Chronic Renal Failure. Nephron, 75, 36–40.
References
• Greenwald, S. E. (2007). Ageing of the conduit arteries. Journal of Pathology, 211, 157–
172.
• Hayashi, K., Sugawara, J., Komine, H., Maeda, S., & Yokoi, T. (2005). Effects of aerobic
exercise training on stiffness of central and periperal arteries in middle-aged sedentary
men. Japanes Journal of Physiology, 55, 235–239.
• Headley, S, Germain, M., Mailloux, P., Mulhern, J., Ashworth, B., Burris, J., … Nindl
Coughlin,M.,Welles,R.,Jones,M., B. (2002). Resistance training improves stgrength and
functional measures in patients with end-stage renal disease. Am J. Kidney Dis, 40(2),
355–364.
• Headley, Samuel, Germain, M., Milch, C., Pescatello, L., Coughlin, M. A., Nindl, B. C., …
Wood, R. (2012). Exercise training improves HR responses and V˙O2peak in predialysis
kidney patients. Medicine and science in sports and exercise, 44(12), 2392–9.
doi:10.1249/MSS.0b013e318268c70c
• Heifets, M., Davis, T. A., Tegtmeyer, E., & Klahr, S. (1987). Exercise Training ameliorates
progressive renal disase in rats with subtotal nephrectomy. Kidney International, 32,
815–816,817,818,819,820.
References
• Jaber, B. L., & Madias, N. E. (2005). Progression of chronic kidney disease: can it be
prevented or arrested? The American Journal of Medicine, 118(12), 1323–1330. Retrieved
from http://ezproxy.spfldcol.edu/login?url=http://search.ebscohost.com/login.aspx?
direct=true&db=cmedm&AN=16378772&loginpage=login.asp&site=ehost-live
• Johansen, K. L., & Painter, P. (2012). Exercise in individuals with CKD. American journal of
kidney diseases : the official journal of the National Kidney Foundation, 59(1), 126–34.
doi:10.1053/j.ajkd.2011.10.008
• Levey, A. S., & Stevens, L. A. (2010). Estimating GFR using the CKD Epidemiology
Collaboration (CKD-EPI) creatinine equation: more accurate GFR estimates, lower CKD
prevalence estimates, and better risk predictions. American Journal Of Kidney Diseases:
The Official Journal Of The National Kidney Foundation, 55(4), 622–627. Retrieved from
http://ezproxy.spfldcol.edu/login?url=http://search.ebscohost.com/login.aspx?
direct=true&db=mnh&AN=20338463&site=ehost-live
• Macdonald, J. H., Fearn, L., Jibani, M., & Marcora, S. M. (2012). Exertional fatigue in
patients with CKD. American journal of kidney diseases : the official journal of the National
Kidney Foundation, 60(6), 930–9. doi:10.1053/j.ajkd.2012.06.021

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Exercise and Chronic Kidney Disease

KDOQI Guidelines (2005)

Stage Description GFR (mL/min/1.73m2)

Levey et al. (2010)

NHANES 1988–1994 & 2005–2010 participants age 20 & older;

Counts projected using

Patients followed for 7 years

• LTPA is associated with decreased

• VO2peak is a strong predictor of

Macdonald et al. (2012)

Johansen & Painter (2012)

• Kidney function normally declines at the rate

Jaber & Madias (2005)

• There is some evidence from animal studies

Beddhu et al. (2009)

Johansen & Painter (2011)

Greenwald (2007), Maeda et al. (2005), Otsuki et al. (2007)

Weiner & Seliger (2014)

Headley et al. (2012)

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