1. Exercise on Dialysis Exercise rehabilitation in Chronic Kidney Disease Dr Alex Crowe Countess of Chester Hospital

2. Physiological capacity, functional capacity and functional status in ESRD Compared with age, gender and physical activity-matched healthy control subjects ESRD patients are characterised by:  35% impairment of peak aerobic power (VO 2 peak)   60% impairment of muscle function (strength, power)  75% of ESRD patients report  physical activity & functional status

3. VO 2 peak and survival Survival as function of baseline VO 2peak for 175 ambulatory ESRD patients (Sietsema et al 2004 Kidney International, 65, 719-724) > 

4. Limiting Factors to Exercise in ESRD Anaemia Autonomic Dysfunction Cardiovascular Dysfunction Abnormal Peripheral Metabolism Skeletal Muscle Structure & Function ------------------------ ------------- ---------------------------- - ----------- Physical Inactivity

5. Disuse-Disability Spiral

6. Exercise Intervention Formats Prescribed supervised exercise  In dialysis unit (Koufaki et al, 2002)  In rehabilitation gymnasium (Mercer et al, 2002) Prescribed unsupervised exercise  Cycle ergometer at home (Konstantinidou et al., 2002)  Walking at home (Painter et al., 2000) Unsupervised exercise  Coaching & counselling (information, video)  Walking & exercise diary (Fitts et al, 1999) Encouragement to be physically active  Education & counselling (information, demonstration)  Lifestyle & activity choices (Tawney et al., 2000)

7. Structured Supervised Exercise Haemodialysis Unit  dialysis day (before & during dialysis)  non-dialysis day CAPD & HD  rehabilitation gymnasium

8. Gas analyser

9. Exercise Training Modes Aerobic Training  Cycle ergometer (on & off-dialysis)  Walking (CAPD and HD non-dialysis days) Resistance Training  Body weight resisted exercises  Light weights & Therabands  Fixed weight machines Combined Aerobic and Resistance Training  Circuit training (CAPD)  Higher-intensity interval training HD

10. Safety: Contraindications & Exclusion Criteria Uraemic complications  Hyperkalaemia  Excess inter-dialytic weight gain Cardiovascular complications  Recent MI  Severe hypertension  Pulmonary congestion  Peripheral oedema Uncontrolled diabetes Recent cerebrovascular event  Residual weakness  Balance disturbance

11. Safety: Exercise During Haemodialysis Stationary cycling during dialysis Safe and effective  Moore et al. (1993 & 1998)  VO 2 Peak on and off dialysis  Unaffected by prior 1 hour of HD  Safe at least up to 2 hours Associated with  frequency of:  Symptomatic hypotension  Muscle cramping  Post-haemodialysis fatigue More efficient fluid removal?

12. Safety of Exercise Training Exercise tolerance assessment  Individualised exercise prescription  Based on VO 2 Peak Warm-up  Regular monitoring during exercise sessions  Heart rate, blood pressure, Ratings of Perceived Exertion, work rate Cool-down Controlled Progression  Establish behaviour (make it routine)  Increase exercise tolerance (gradually  duration) Periodic reassessment of exercise tolerance  Individualised exercise prescription

13. Feasibility of Exercise Training Staff support  Physicians, nurses, dieticians, physiotherapists, occupational therapists Patient interest  Patient Associations  Unit newsletter  Dialysis unit ‘culture’ Patient profile  People are different! Exercise modes/equipment available  Be creative  Match exercise to patient and not vice versa

14. Bikes

15. Paraphernalia

16. Testing

17. Incremental exercise testing  3 minutes unloaded  Every minute 15 W  RPE every min  Until patient can tolerate  Measure VO 2 peak

18. Short exercise capacity test (SECT)  Strength testing  3 minutes unloaded  Every 15 sec ↑ by 15W  Measure maximal power  Exercise prescription is based on 50% of this

19. Training

20. Exercise Training Studies 32 exercise training studies published since 1979  Randomised controlled, non-randomised controlled and uncontrolled Most common outcome measures  VO 2 peak  Peak exercise capacity (watts)  Quality of life  Psychological well-being  Self-reported functional status Other reported outcome measures  Functional capacity (sit-to-stand, walk tests)  Heart rate variability  Muscle morphology/biochemistry  Nutritional state (SGA)

21. Randomised Controlled Studies 9 randomised controlled studies  163 exercisers (9-43 per study)  121 controls (6-30 per study)  Age (36-59) Programme characteristics  Duration: 6 months (3-12)  Exercise frequency: 3 (3-5) per week  Exercise duration: 20-60 min  Exercise intensity:  60-80% HRmax  90% Ventilatory Threshold Median  VO 2 peak =  24% (0-43%)

22. Non-Randomised Controlled Studies 6 non-randomised controlled studies  50 exercisers (5-13 per study)  36 controls (4-7 per study)  Age (38-62) Programme characteristics  Duration: 4 months (2.5-39)  Exercise frequency: 3 (2-5) per week  Exercise duration: 30 min (15-60)  Exercise intensity:  60-80% HRmax  RPE 13 Median  VO 2 peak =  17% (0-23%)

23. Uncontrolled Studies 9 uncontrolled studies  65 exercisers (7-18 per study)  Age (42-60) Programme characteristics  Duration: 6 months (2-6)  Exercise frequency: 3 (3-5) per week  Exercise duration: 30 minutes (12-60)  Exercise intensity:  60-80% HRmax  90% Ventilatory Threshold Median  VO2 peak =  18% (0-48)

24. Effectiveness of Exercise Training Few studies involve direct comparisons of types of exercise Konstantinidou et al. (2002) 6 month study (~50 years age)  (A) Supervised outpatient renal rehabilitation  3 x 60 min/week (30' intermittent aerobic exercise; 60-70 HRmax + resistance training) Maintenance: basketball & swimming  (B) Exercise during dialysis  3 x 60 min/week (bed cycle ergometer; 30 min continuous aerobic exercise; 70% HRmax + lower limb strength & flexibility exercise  (C) Unsupervised home-based moderate exercise  5 x 30 min/week (cycle ergometer; 50-60% HRmax + flexibility and muscular endurance exercises)  (D) Control group

25. Effectiveness of Exercise Training Findings: (A) Supervised outpatient  Dropout = 24%  Peak exercise capacity = 43% (B) On dialysis  Dropout = 17%  Peak exercise capacity = 24% (C) Home-based  Dropout = 17%  Peak exercise capacity = 17%  Exercise on non-dialysis days most effective  Exercise training during HD technically feasible and effective  Unsupervised exercise was effective and safe

26. Potential of Exercise Rehabilitation   Exercise tolerance & functional capacity   Capability for activities of daily living   Comorbidity (B.P., Insulin Resistance)   Quality of Life & psychological well-being  Anabolic effect (  muscle mass)