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Exercise Guidelines for Chronic Kidney Disease Patients

  • Rita Huie Milam
    Correspondence
    Address correspondence to Rita Huie Milam, MA, RDN, CSR, CDE, LD, Department of Nutrition and Food Services, Central Arkansas Veterans Healthcare Systems, 4300 West 7th Street, Little Rock, Arkansas 72205.
    Affiliations
    Department of Nutrition and Food Services, Central Arkansas Veterans Healthcare Systems, Little Rock, Arkansas
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      Chronic kidney disease (CKD) patients are often overlooked when it comes to exercise programs.
      • Delgado C.
      • Johansen K.L.
      Deficient counseling on physical activity among nephrologists.
      Although the medical community, specifically, a majority of nephrologists are of the opinion that their patients should engage in regular exercise to improve overall health.
      • Howden E.J.
      • Coombes J.S.
      • Strand H.
      • et al.
      Exercise training in CKD: efficacy, adherence, and safety.
      Physical inactivity contributes to a reduction in activities of daily living and reduced quality of life.
      • Hiraki K.
      • Yasuda T.
      • Hotta C.
      • et al.
      Decreased physical functioning pre-dialysis patients with chronic kidney disease.
      By enhancing the strength of their muscles, bones, and joints through exercising, people with CKD can improve their balance and coordination.
      • Chan M.
      • Cheema B.S.
      • Fiatarone Singh M.A.
      Progressive resistance training and nutrition in renal failure.
      This can further prevent them from falling and likewise, protect their independence as they age. Moreover, it is widely known that CKD patients are at high risk for premature death as a result of cardiovascular disease due in part to their sedentary behavior.
      • Greenwood S.A.
      • Koufaki P.
      • Mercer T.H.
      • et al.
      Effect of exercise training on estimated GFR, vascular health, and cardiorespiratory fitness in patients with CKD: a pilot randomized controlled trial.
      By increasing the physical activity levels of individuals with CKD, it is possible to decrease their risk of cardiovascular disease and improve their physical functioning, thus preventing premature death.
      • Greenwood S.A.
      • Koufaki P.
      • Mercer T.H.
      • et al.
      Effect of exercise training on estimated GFR, vascular health, and cardiorespiratory fitness in patients with CKD: a pilot randomized controlled trial.
      More recently, studies have evaluated the possibility that increasing physical activity levels may slow the rate of decline of estimated glomerular filtration rate in patients with CKD stages 3 to 4.
      • Greenwood S.A.
      • Koufaki P.
      • Mercer T.H.
      • et al.
      Effect of exercise training on estimated GFR, vascular health, and cardiorespiratory fitness in patients with CKD: a pilot randomized controlled trial.
      • Castaneda C.
      • Gordon P.L.
      • Uhlin K.L.
      • et al.
      Resistance training to counteract the catabolism of a low-protein in patients with chronic kidney disease.
      The latest Kidney Disease Improving Global Outcomes Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease lifestyle section recommends that individuals with CKD engage in physical activity for at least 30 minutes per day, 5 times per week.
      KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease.
      Besides counseling CKD patients on nutrition modifications, registered dietitian nutritionists (RDNs) especially those with expertise in renal nutrition and nephrology are in a position to also facilitate their patients in recommendations for increasing their physical activity levels. The RDN should begin by using the initial nutritional assessment to determine the activity level of the CKD patient. A Low Physical Activity Questionnaire has been developed to assess and can additionally be used for monitoring physical activity.
      • Johansen K.L.
      • Painter P.
      • Delgado C.
      • Doyle J.
      Characterization of physical activity and sitting time among patients on hemodialysis using a new physical activity instrument.
      Although it was developed for patients on hemodialysis, this instrument would also be pertinent for use with the CKD patient population. After identifying areas to improve on, the RDN may recommend structured activities including aerobic, strength, and flexibility exercises. A combination of all three types of exercises performed five times a week and using different muscle groups each day would improve the CKD patient's endurance and strength.
      • Kosmadakis G.C.
      • Bevington A.
      • Smith A.C.
      • et al.
      Physical exercise inpatients with severe kidney disease.
      It is important that the RDN ensures that the suggested exercises be individualized to the CKD patient's current stage of physical ability. Implementing an exercise program along with nutrition modifications can be challenging for both the RDN and the CKD patient. However, with continued follow-up monitoring and adjustments along the way, patients with CKD can improve their overall health and well-being. The corresponding patient education handout is designed to provide clinicians with a starting point for implementing an exercise program with their CKD patients.

      Exercise Guidelines for CKD Patients

      Why Exercise?

      People with chronic kidney disease (CKD) can benefit from exercising regularly just like those without this condition. Your quality of health can improve if you engage in activities that strengthen the muscles, bones, and joints in your body. This can improve your balance and coordination which can prevent you from falls and protect your independence as you grow older.
      Other physical exercise benefits also include improved blood pressure and diabetes control. Sometimes these diseases can worsen when the kidneys are damaged, and more medications may have to be added to those that you are taking currently. Exercising regularly may help lower your blood pressure and keep it from further damaging the kidneys. In the same way, exercise helps to lower your blood sugar levels throughout the day and night and puts less stress on the kidneys.

      What Types of Exercises Are Best?

      Structured activities include aerobic, strength, and flexibility activities. Aerobic activities are where you use large amounts of oxygen. These types of exercises include walking, jogging, stair climbing, swimming, water walking and water aerobics, gardening, dancing, bicycling, and chair exercises. Other types of aerobic exercises can be performed on machines such as a treadmill, stationary bike, or elliptical trainer.
      Strength training involves using large muscles of your body to perform activities. For instance, free weights or dumbbells, resistance bands and tubes, Pilates, and medicine balls aid in strengthening your muscles. Flexibility type activities move your joints through their full range of motion and help to lessen your risk of injury when performing physical activities. These include stretching, Yoga, and Tai Chi.
      Chronic kidney disease should not hold you back from living life to its' fullest.

      How Much Should I Exercise?

      If you have not already been exercising regularly, you will want to start slowly and work up to a pace that you are comfortable with each day. Ideally, you will want to engage in exercise—aerobic, strengthening, or flexibility activities—5 times per week. If you can get in a habit of exercising at the same time each day, it will be less of a chore and more of a routine of living healthfully, just like eating your meals.
      For instance, begin and end your workout with stretching exercises and follow with either an aerobic activity such as walking or strength training such as lifting handheld weights. A combination of these activities using different muscle groups each day such as the upper body 1 day and the lower body another will improve your health over time.

      How Can I Stay Safe While Exercising?

      The main thing to remember when exercising is to listen to your body. Keep in mind that exercising regularly is healthier than not exercising at all. But if you do develop any of the following problems, stop what you are doing and seek medical help:
      • Muscle cramps or joint pain
      • Nausea or vomiting
      • Pain in the upper part of your body including your face and jaw
      • Problems seeing, speaking, or trouble swallowing
      • Shortness of breath that is not normal
      • Sudden headache, dizziness, or a feeling of lightheadedness
      • Sudden weakness in your arms or legs
      Chronic kidney disease should not hold you back from living life to its' fullest. It may mean that you will need to put forth more effort to improve your health and exercise regularly. You may want to seek the support from family and friends to help you along the way. Often, you may need the encouragement of others to help motivate you to continue and stay on course. Do not hesitate to ask those close to you for their help.

      Exercise Ideas for Aerobic, Strength and Flexibility Workouts

      Aerobic

        Walking Program:

      • 1.
        Begin by walking at a slow but steady pace for 10 minutes 5 days a week.
      • 2.
        Once comfortable with the walking 10 minutes daily, then increase to 20 minutes every other day at a brisk pace.
      • 3.
        At 1 month, increase your time to 30 minutes every other day.
      • 4.
        Then, after 1 month, walk 30 minutes 5 times a week.
        At this point, you will be walking long enough and with the right amount of effort to gain the benefits of exercise and improve your health.

      Strength

        Toe Raises:

      • 1.
        Stand straight with your hands on a counter or rail for support. Slowly raise your heels up off the floor and count to two.
      • 2.
        Then lower your heels back down to the floor. Repeat 8 to 12 times.

        Leg Lifts:

      • 1.
        Sit in a chair where your back is straight and your knees are bent and feet are flat on the floor. Lift and straighten your right leg and hold for a few seconds. Lower your right leg to the starting position.
      • 2.
        Repeat using your left leg. Perform exercise 8 to 12 times with each leg.

      Flexibility

      Stretching exercises will help to lengthen and loosen your muscles and joints. Perform these as a warm-up and cool down part of your overall exercise plan.

        Shoulder Rotations:

      • 1.
        While standing or sitting, move the top of your right shoulder forward in a circular motion for 15 to 30 seconds.
      • 2.
        Repeat with your left shoulder.

        Leg Stretches:

      • 1.
        While lying on your back, bend your right leg and keep your left leg straight.
      • 2.
        With both your hands placed behind your right leg, pull your thigh toward your chest and hold for 15 to 30 seconds.
      • 3.
        Repeat with your left leg.

      Motivational Statements

      Exercise for the Health of It!
      Try to do some type of exercise every day.
      Be patient with yourself and stick with it.
      YOU can do it!

      References

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        • Johansen K.L.
        Deficient counseling on physical activity among nephrologists.
        Nephron Clin Pract. 2010; 116: c330-c336
        • Howden E.J.
        • Coombes J.S.
        • Strand H.
        • et al.
        Exercise training in CKD: efficacy, adherence, and safety.
        Am J Kidney Dis. 2015; 65: 583-591
        • Hiraki K.
        • Yasuda T.
        • Hotta C.
        • et al.
        Decreased physical functioning pre-dialysis patients with chronic kidney disease.
        Clin Exp Nephrol. 2013; 17: 225-231
        • Chan M.
        • Cheema B.S.
        • Fiatarone Singh M.A.
        Progressive resistance training and nutrition in renal failure.
        J Ren Nutr. 2007; 17: 84-87
        • Greenwood S.A.
        • Koufaki P.
        • Mercer T.H.
        • et al.
        Effect of exercise training on estimated GFR, vascular health, and cardiorespiratory fitness in patients with CKD: a pilot randomized controlled trial.
        Am J Kidney Dis. 2015; 65: 425-434
        • Castaneda C.
        • Gordon P.L.
        • Uhlin K.L.
        • et al.
        Resistance training to counteract the catabolism of a low-protein in patients with chronic kidney disease.
        Ann Intern Med. 2001; 135: 965-976
      1. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease.
        Kidney Int Suppl. 2013; 3: 79-80
        • Johansen K.L.
        • Painter P.
        • Delgado C.
        • Doyle J.
        Characterization of physical activity and sitting time among patients on hemodialysis using a new physical activity instrument.
        J Ren Nutr. 2015; 25: 25-30
        • Kosmadakis G.C.
        • Bevington A.
        • Smith A.C.
        • et al.
        Physical exercise inpatients with severe kidney disease.
        Nephron Clin Pract. 2010; 11: c7-c16