Journal of Science and Medicine in Sport 16 (2013) 406–411

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Journal of Science and Medicine in Sport

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Review

Exercise & Sports Science Australia (ESSA) position statement on exercise and
chronic kidney disease
Neil A. Smart a,∗ , Andrew D. Williams b , Itamar Levinger c,1 , Steve Selig d , Erin Howden e ,
Jeff S. Coombes e , Robert G. Fassett e,f
a
School of Science and Technology, University of New England, Armidale, NSW 2351, Australia
b
School of Human Life Sciences, University of Tasmania, Launceston 7250, Australia
c
Institute for Sport, Exercise and Active Living (ISEAL), College of Sport and Exercise Science, Victoria University, Melbourne, Australia
d
Centre for Exercise and Sports Science, Deakin University, Victoria, Australia
e
School of Human Movement Studies, University of Queensland, St. Lucia, QLD, 4072, Australia
f
Department of Renal Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, 4029, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: Chronic kidney disease (CKD) is prevalent, affecting 13% of adult Australians and poses
Received 6 November 2012 increased risk for cardiovascular morbidity and mortality. This position article provides evidence-based
Received in revised form 19 January 2013 guidelines on the role of exercise training for CKD patients and provides recommendations for prescribing
Accepted 23 January 2013
and delivering exercise training.
Design: Position stand.
Keywords:
Methods: Synthesis of published work within the field of exercise training and chronic kidney disease.
Exercise training
Results: Exercise training likely to provide benefits to CKD patients, including improvements in cardio-
Chronic kidney disease
Haemodialysis
respiratory fitness, quality of life, sympatho-adrenal activity, muscle strength and increased energy intake
and possible reduction in inflammatory biomarkers. Existing studies generally report small sample sizes,
brief training periods and relatively high attrition rates. Exercise training appears to be safe for CKD
patients with no deaths directly related to exercise training in over 30,000 patient-hours, although strict
medical exclusion criteria in previous studies resulted in 25% of patients being excluded potentially
impacting the generalisability of the findings.
Conclusions: Aerobic exercise at an intensity of >60% of maximum capacity is recommended to improve
cardio-respiratory fitness. Few data are available on resistance training and it is unclear whether this form
of training retards catabolic/inflammatory processes typical of CKD. However, it should be considered
important due to its proven beneficial effects on bone density and muscle mass. Due to the high prevalence
and incidence of co-morbidities in CKD patients, exercise training programs should be prescribed and
delivered by individuals with appropriate qualifications and experience to recognise and accommodate
co-morbidities and associated complications.
© 2013 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

1. Background kidney abnormalities with or without decreased glomerular fil-

tration rate (GFR), or (b) GFR < 60 ml/min/1.73 m2 present > three
This Position Statement provides evidence-based guidelines for months with or without kidney damage.2 A recent update now
exercise training in patients with chronic kidney disease (CKD). also takes into account serum albumin levels when assigning risk
CKD is a complex disease that impacts on multiple organs and of serious events according to eGFR status (see Supplementary
systems. CKD is a major public health problem associated with Table).2 Prognosis for people with CKD is poor and reduced GFR
high morbidity, mortality and costs to the community.1 Kid- is an independent predictor of death, cardiovascular events, and
ney Disease Improving Global Outcome (KDIGO) defines CKD as hospitalization.3,4 CKD has many causes and is associated with
(a) kidney damage ≥ three months with structural or functional metabolic conditions such as obesity, type 2 diabetes and cardio-
vascular diseases.5,6 CKD classification has 5 stages according to
severity, diagnosis, treatment and prognosis, with stage 5 usually
∗ Corresponding author.
described as end stage kidney disease (ESKD).7 CKD is estimated to
E-mail address: [email protected] (N.A. Smart).
affect 13.4% of Australian adults (aged 25 years or older), with more
1
Dr Itamar Levinger is a Heart Foundation Postdoctoral Research Fellow (PR than half of these in stage 3–5. Moreover, 30% of Australian adults
11M6086). aged over 65 years have CKD stage 3–5.8

1440-2440/$ – see front matter © 2013 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jsams.2013.01.005
 N.A. Smart et al. / Journal of Science and Medicine in Sport 16 (2013) 406–411 407

Fig. 1. Lifestyle factors influencing CKD development and progression.

Supplementary material related to this article found, in the • Exercise training had no significant effects on the capacity to
online version, at http://dx.doi.org/10.1016/j.jsams.2013.01.005. perform activities of daily living.
• Exercise training improves central haemodynamics (reduced
blood pressure and resting heart rate). Most benefits were
2. Evidence for benefits of exercise in CKD
observed in those who performed high intensity exercise.
• The effects of exercise training on serum albumin are unclear.
As with related chronic diseases, physical inactivity is a major
• Exercise training significantly increased energy intake following
CKD risk factor9 and a predictor of cardiovascular mortality.10 In
exercise training.
ESKD patients, a peak VO2 below 17.5 ml kg−1 min−1 is associated
• Exercise training did not significantly reduce fat mass or waist
with increased mortality.11 However, the relationship between
circumference.
exercise capacity and mortality has not been reported in CKD stages
• Exercise training did not improve lipid profile or fasting glucose
1–4. Nevertheless, a negative relationship between kidney func-
levels.
tion, anaemia and exercise capacity, measured as peak VO2 has
• Exercise training did not improve left ventricular structure or
been described in CKD patients with stages 4 and 5.12 Fig. 1 illus-
function.
trates the connection between sedentary lifestyle and CKD.
• Dropout rate varied widely amongst studies, ranging from 0 to
The importance of modifying lifestyle for medical management
70%.
of CKD is evident in many exercise training studies.13 Regular
• In most studies the compliance was 70% or greater.
exercisers have better quality of life, physical functioning, sleep
quality scores, report fewer physical activity limitations and are
less affected by pain or poor appetite. In models adjusted for
Hence, exercise training can improve aerobic capacity, mus-
demographics, co-morbidities and socio-economic indicators, mor-
cle strength and some psychological measures in CKD patients.
tality risk was 27% lower among regular exercisers.14 Several
Exercise may improve kidney function which is measured by
exercise training reviews and meta-analyses for CKD have been
estimated glomerular filtration rate (eGFR). Overall, the optimal
published13,15–19 the consensus is that regular exercise is benefi-
“dose” of exercise that will lead to improve clinical measures in
cial for patients in CKD stages 1–4 and stage 5 (ESKD), with the
this population is unclear. Differences between individual stud-
majority of evidence being for ESKD. Furthemore, a recent exten-
ies illustrate the difficulties translating existing data into practice
sive Cochrane review examined the aerobic and resistance training
(see Table 1). About two thirds of published trials are <6 months
effects on functional and clinical measures related to CKD.13 The
duration and thus may be sub-optimal for achieving changes in
review highlights that:
desired outcomes.20 All but two studies in Table 1 present data in
haemodialysis patients.
• Both low and high intensity aerobic exercise resulted in increased Only four studies utilised isolated resistance training, so the
aerobic capacity, but, high intensity exercise produced larger specific effects of resistance training in CKD patients are poorly
increases. understood. Although a greater number of aerobic and combined
• Resistance training alone had no significant effect on aerobic training studies exist, study duration, intensity, frequency, exer-
capacity. cise modality, venue (home versus outpatient versus inter-dialytic)
• Supervised exercise programs are associated with greater bene- are so varied it is difficult to determine optimal exercise pre-
fits than unsupervised exercise. scription. Nevertheless, the limited existing evidence on exercise
• Muscle strength is likely to increase with both aerobic and resis- intensity suggests greater benefit from moderate or higher inten-
tance type exercises, but more with resistance training. Muscle sity rather than low intensity exercise, for a range of markers
endurance (sit-to-stand in 60 s) is not likely to increase with exer- related to physical function and cardiovascular health.13 Many
cise (both resistance and aerobic). ESKD patients exhibit inflammation, muscle wasting and poor
408 N.A. Smart et al. / Journal of Science and Medicine in Sport 16 (2013) 406–411

Table 1
Published randomized, controlled studies of exercise training in CKD patients versus sedentary control.

Aerobic training studies N (ExT) CKD stage Training Study duration, delivery method Data extracted

Chang47 71 (36) HD AT 2 Months, ID Cycling ↓Fatigue

Cheema21 49 (24) HD RT 3 Months, Strength ID ↑Strength
Cheema25 49 (24) HD RT 3 Months RT, ID Cytokines–no change
Chen J.48 50 (25) HD RT 4 Months ID ↑Strength, ↑↓ADL
Chen P.Y.49 94 (45) CKD 2–4 AT 3 Months, HD Biochemistry, no change
Daniilidis50 34 (20) HD AT 3 Months, ID ↓IL-6
Deligiannis29 60 (30) HD CT 6 Months, ND ↑Peak VO2 , ↑HRV
Deligiannis30 16 (12) HD CT 6 Months, ND ↑Peak VO2 , ↑LVEF %
Dong23 32 (15) HD RT 6 Months Diet plus ExT vs Diet ↓Body Mass and ↑Strength
Frey26 11 (5) HD AT 2 Months, ID ↑Energy Intake
Johansen22 79 (40) HD RT 3 Months, ID ↑Muscle size, ↑strength, ↑SF-36†
Koh37 70 (43) HD AT 6 Months, Cycling, ID ↑SF-36
Koufaki27 18 (15) HD AT 3 Months, Cycling, ID ↑Peak VO2 , ↑Energy Intake
Kouidi31 31 (20) HD AT 6 Months, various aerobic, ND ↑Peak VO2 , ↓Depression
Kouidi51 48 (24) HD CT‡ 4 Years, Aerobic & Strength ND Home v outpatient ↑Peak VO2
Kouidi32 59 (30) HD CT 10 Months, Cycling ID ↑Peak VO2
Leehey36 11 (7) CKD 2–4 AT 6 Months Home eGFR, HbA1 C, lipids, calories, body mass all no change
Moros-Garcia33 34 (23) HD AT 4 Months, Cycling ND ↑Peak VO2
Oliveros52 15 (9) HD CT 4 Months ND ↑Strength, ↑QOL, Cytokines
Painter34 24 (10) HD AT 5 Months, Cycling, ID ↑Peak VO2
Parsons53 13 (6) HD AT 2 Months Cycling, ID ↑SF-36
Reboredo38 22 (11) HD AT 3 Months, ID ↑HRV and ↑LVEF
Van Vilsteren35 96 (53) HD CT 3 Months, Cycling/Strength ID ↑Peak VO2 , ↑SF-36
Wilund54 17 (8) HD AT 4 Months, ID CYCLING ↓Oxidative stress and body fat

Abbreviations: AT, aerobic training; RT, resistance training; CT, combined training; ID, intra-dialytic training; ND, non-dialysis training; HD, haemodialysis; HRV, heart rate
variability; LVEF, left ventricular ejection fraction.
†
Some patients also received nandralone.
‡
Compared home versus outpatient exercise training.

nutrition. Several resistance training studies21–25 have produced change in peak VO2 of 18 ± 8% while training on non-dialysis days
improvements in muscle strength, although concomitant reduc- showed 34 ± 6% improvement in peak VO2 (p = 0.03).20
tions in pro-inflammatory cytokine expression are ambiguous.24,25 Improvements in physical fitness are related to improved qual-
Elevated cytokine expression and poor nutrition are associated ity of life and decreased depression in CKD patients.17 Assessments
with catabolism and CKD disease progression. Two studies26,27 using the short-form-36 (SF-36) general health questionnaire37
employed dietary recall to estimate daily energy intake, which and the Beck Depression Inventory31 have been conducted in CKD
increased in exercising CKD participants by approximately 5% from patients before and after exercise training interventions, although
baseline. However, recent work has failed to show additional ben- limited existing data cannot demonstrate any significant change in
efit of exercise training over oral nutritional supplementation in either measure.
CKD patients.23 Two studies showed significant improvements in heart rate
Published aggregate data exists on approximately 1000 study variability30,32 with 6 months exercise training, although a shorter
participants where, generally, exercise and control groups are 3 month study reported no change.38 The former studies suggest
extremely well matched at baseline for age, gender, erythropoi- long-term (6 months) exercise training has a favourable sympatho-
etin use and peak VO2 , time receiving haemodialysis and co-morbid adrenal effect in CKD patients. Cardiovascular disease is a common
disease prevalence. A recent meta-analysis reported study designs cause of death in CKD patients3,39 therefore exercise-induced
were generally poor with median Jadad score of 2.20,28 Only about a improvements in sympatho-adrenal function may reduce cardio-
third of published studies provide complete CONSORT statements, vascular mortality risk.
and in many data on eligibility, withdrawal and completion were
deficient. Most studies failed to conduct intention to treat analyses, 3. Exercise prescription-recommendations
which could quantify impact of study withdrawals. Available data
suggests about 25% of patients approached are ineligible due to var- Before prescribing exercise each CKD patient should undergo
ious medical exclusion criteria, a further 28% refused to participate, a thorough medical review. One should first take a full medical
so exercise may be underutilised in CKD. Exercise training appears history and clinical examination including cardiovascular assess-
safe with no deaths reported directly due to exercise training in ment including blood pressure. In addition, a detailed medication
over 30,000 patients-hours.20 Published studies show no evidence usage history and review of recent biochemistry and haematol-
of publication bias, with low to moderate heterogeneity. ogy will inform prescription to potentially reduce adverse clinical,
Nine studies27,29–36 measured peak VO2 in a total of nearly 400 biochemical, haematological and medication-exercise interactions.
patients. Mean baseline ± standard deviation of peak VO2 for both Subsequently baseline cardiopulmonary exercise testing with 12-
exercise and control participants was 21.0 ± 5.0 ml kg−1 min−1 . lead ECG is recommended to; (i) establish those unsuitable for
Mean age was 51 years and the age-predicted peak VO2 for a 51 year exercise or those who first require medical stabilization, and
old, sedentary, non-obese adult is 28.8 ml kg−1 min−1 indicating (ii) provide data for an individually tailored exercise prescrip-
CKD patients have a peak VO2 about 70% of age-predicted value.20 tion.
Exercise training may be beneficial as low peak VO2 is associated In line with the 2011 Cochrane review on exercise in adults with
with increased mortality risk.11 Data from studies of combined CKD,13 current scientific evidence supports exercising regularly
aerobic and strength training convey a weighted mean 29 ± 11% for >30 min/session three times/week to improve physical fitness,
improvement in peak VO2 , similar to the 23 ± 10% from isolated cardiovascular dimensions and health related quality of life.13
aerobic studies. Peak VO2 data from resistance training studies is Similarly the recent Kidney Disease Improving Global Outcomes
unavailable. Intra-dialytic training (ID) produced weighted mean document recommends that people with CKD be encouraged to
 N.A. Smart et al. / Journal of Science and Medicine in Sport 16 (2013) 406–411 409

Table 2
Guidelines for aerobic and resistance exercise prescriptions in ESKD patients undertaking (non-nocturnal) haemodialysis.

ESKD inter-dialysis ESKD intra-dialysis Non-dialysis

Aerobic
Session duration Build up to 30–45 min Build up to 30–45 min Build up to 30–45 min
Session timing Non-dialysis days During first 2 h of dialysis According to patient needs
Intensity (% max. HR) or RPE (6–20 55–70% max HR, RPE 11–13 Moderate 55–70% max HR, RPE 11–13 55–90% max HR, RPE 11–16 moderate
point scale) (preferably >60% max HR) moderate (preferably >60% max to vigorous (60–90% max HR)
HR)
Weekly duration Up to 180 min Up to 180 min Up to 180 min
Modality Walking/cycling/other Cycling while seated using arm or Walking/jogging/cycling/other
leg ergometer
Resistance*
Initial frequency per week Two non-consecutive days Two non-consecutive days Two non-consecutive days
Different muscle groups/exercises 8–12 exercises prioritizing major muscle Up to 12, as many as practical in 8–12 exercises (major muscles)
groups dialysis session
Initial volume 1 set to fatigue, 12–15 reps or 60–70% 1 set to fatigue, 12–15 reps or 1 set to fatigue, 10–15 reps or 60–70%
Repetition Maximum 60–70% Repetition Maximum repetition maximum
Timing Non-dialysis days Before or during dialysis As comfortable
Modality Weight-bearing activity, thera-bands, Weight-bearing activity, Weight-bearing activity, thera-bands,
weight cuffs, light dumbbells, weight thera-bands, weight cuffs, light machine and free weights.
machines dumbbells – as practical in dialysis
Indications Cachexia, poor bone density, low BMI or Cachexia, poor bone density, low Cachexia, poor bone density, low BMI
lean body mass BMI or lean body mass or lean body mass
Flexibility 5–7 days per week for a duration of about 10 min per session. Where possible combine with aerobic or resistance exercise
session and include balance exercises for those at risk of falls.
*
Both resistance and aerobic activity should be completed (although not necessarily in the same session); recommendations assume no contraindications to exercise.
Abbreviations: Reps, repetitions; BMI, body mass index; RPE, rate of perceived exertion; HR, heart rate.

undertake physical activity compatible with cardiovascular health In ESKD patients several additional considerations must be
and tolerance (aiming for at least 30 min 5 times per week).2 It taken into account. CKD patients often exhibit significant physical
is suggested that exercise training include aerobic, resistance and deconditioning and co-morbidities. Larger adaptations may occur
flexibility activities and that clinical judgement should determine when exercise is completed on non-dialysis days, although intra-
the relative contributions of each. Individual recommendations by dialytic exercise training may produce better adherence rates, but
stage and/or treatment modality of kidney disease do not presently exercise should be within the first 2 h of dialysis initiation.18 Per-
exist, however, the following suggestions may guide exercise pre- itoneal dialysis patients perform exercise more comfortably with
scription for the CKD/ESKD patient. abdominal cavities emptied of dialysis fluid, reducing diaphrag-
Patients with peak VO2 values (<17.5 ml kg−1 min−1 ) may derive matic pressure, breathlessness and, in some types of peritoneal
the largest survival benefit from exercise training.11 Training dialysis, chest discomfort. Haemodialysis patients should avoid
should be performed in the presence of qualified clinical staff. upper limb activity with temporary or healing arterio-venous fis-
Cachectic patients exhibiting poor bone density or low body mass tulas. Fistula arms should not be used for functional assessment,
index (<20 kg m−2 ) should commence resistance exercise as soon as thus avoiding false blood pressure testing and using the fistula arm
possible. Resistance training during dialysis is limited by sitting, we for blood pressure measurement is contraindicated. A role exists
have therefore taken a practical, evidence based approach to aer- for both intra and interdialytic exercise with exercise adherence
obic and resistance exercise prescription, see Table 2. Based upon tending to be greater in the former, due to increased supervi-
a meta-analysis,18 5 studies with statistically significant improve- sion. Interdialytic exercise also results in improved outcomes when
ments in peak VO2 had the following attributes; all were >6 months adherence is maintained.45 We recommend patients perform exer-
duration, all but one used >240 min weekly (90 min or more exer- cise during the first 2 h of haemodialysis, when blood pressure
cise session durations) and exercise intensities were 60–70% of control is best.
predicted heart rate maximum. Based partially on previous work40 Regular blood pressure and electrocardiogram (ECG) monitor-
we also recommend resistance exercise on twice weekly on non- ing during exercise training is recommended, especially when ECG
consecutive days, details of sets and repetitions can be seen in a is affected by electrolyte abnormalities (e.g. hypo/hyperkalaemia).
Table 2. If this occurs a nephrologist consultation is recommended.

4. Special considerations 5. Contraindications to exercise

While studies reporting exercise benefits have not reported any In addition to the American College of Cardiology Founda-
safety issues arising from exercise interventions,13 identification tion/American Heart Association contraindications to exercise46
and appropriate management of any co-morbidities is essential the following are specific to CKD patients:
for safe exercise delivery. In their excellent review, Johansen and
Painter state that exercise appears to be safe in the CKD patient pop- Electrolyte abnormalities – especially hypo/hyperkalaemia
ulation if begun at moderate intensity and increased gradually.41 Recent changes to the ECG, especially symptomatic tachy-
Moreover, the evidence suggests that the risk of remaining inactive arrhythmias or brady-arrhythmias
is higher.41 Exercise should be tailored to accommodate additional Excess inter-dialytic weight gain >4 kg since last dialysis or exer-
co-morbidities as well as CKD. Recommendations for several com- cise session
mon co-morbidities including hypertension, type II diabetes and Unstable on dialysis treatment and changing (titrating) medica-
cardio-myopathies have already been published.42,43 Those with tion regime
diabetic nephropathy36 and cardio-renal syndrome44 require clos- Pulmonary congestion
est supervision. Peripheral oedema
410 N.A. Smart et al. / Journal of Science and Medicine in Sport 16 (2013) 406–411

6. Gaps in the literature 13. Heiwe S, Jacobson SH. Exercise training for adults with chronic kidney disease.
Cochrane Database Syst Rev 2011 (10): CD003236.
14. Tentori F, Elder SJ, Thumma J et al. Physical exercise among participants in the
There exists the need for large, well-designed randomized, con- Dialysis Outcomes and Practice Patterns Study (DOPPS): correlates and associ-
trolled trials with reliable outcome measures that will provide ated outcomes. Nephrol Dial Transplant 2010; 25(9):3050–3062.
exercise dose (intensity, frequency, duration and modality) for peo- 15. Cheema BS, Singh MA. Exercise training in patients receiving maintenance
hemodialysis: a systematic review of clinical trials. Am J Nephrol 2005;
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whether aerobic or resistance exercise or a combination of both 16. Johansson P, Dahlstrom U, Brostrom A. Factors and interventions influencing
will provide optimal benefits to ESKD patients with cachexia. Only health-related quality of life in patients with heart failure: a review of the
literature. Eur J Cardiovasc Nurs 2006; 5(1):5–15.
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there exists obvious need for further trials examining the possible Nefrologia 2010; 30(2):236–246.
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kidney disease: a systematic review. Am J Med 2011; 124(11):1073–1080, e1072.
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