RESEARCH PROPOSAL

IMPACT OF EXERCISE/REHABILITATION ON QUALITY OF LIFE AND

PSYCHOLOGICAL WELL BEING OF AN INDIVIDUAL SUFFERING FROM CHRONIC
KIDNEY DISEASE: A LITERATURE REVIEW

BACKGROUND: Chronic kidney disease or chronic renal failure, is a term that

encompasses all degrees of kidney function, from damaged-at risk through mild,
moderate, and severe chronic kidney failure.CKD is a worldwide public health problem.
CKD is more prevalent in elderly patients. However, while younger patients with CKD
typically experience progressive loss of kidney function,30% of patients usually over 65
years of age with CKD have stable disease. Chronic kidney disease, also called chronic
kidney failure, describes the gradual loss of kidney function. The kidneys filter waste
and excess fluids from the blood, which is then excreted in the urine. When chronic
kidney disease reaches an advanced stage, dangerous levels of fluid, electrolytes and
wastes can build up in the body.

Aim: The aim of study is to analyze and critically evaluate literatures for understanding
quality of life and psychological well being of an individual suffering with chronic kidney
disease.

SIGNIFICANCE: Exercise/rehabilitation helps people with disabilities to lead the life that
they would wish, given any restriction imposed on their activities by impairments
resulting from illness or injury as well as from their personal context. The rehabilitative
process is unique in treating people according to a holistic approach or a bio-psycho-
social model with the aim of supporting a person's independent living and autonomy.
Rehabilitation has been demonstrated effective and efficient in reducing the burden of
disability and enhancing the opportunities for disabled people. On the base of clinical,
affective and functional evaluation, physiatrists have to plan the rehabilitative project
including all structural body and functional areas that need of reparative and
rehabilitative interventions.

LITERATURE REVIEW:

INTRODUCTION-

Andrew S Levey et al. Kidney Int. 2005 Jun. Chronic kidney disease (CKD) is a
worldwide public health problem, with adverse outcomes of kidney failure,
cardiovascular disease(CVD), and premature death.

The kidney disease: Improving global outcomes (KDIGO) organization developed

clinical practice guidelines in 2012 to provide guidance on the evaluation, management,
and treatment of chronic kidney disease in adults and children who are not receiving
renal replacement therapy. Paul E Stevens et al. Ann Intern Med. 2013

Douglas W Gould et al. Nephrology(Carlton). 2014 sep CKD is strongly associated

with cardiovascular disease and muscle wasting, arising from numerous factors
associated with declining renal function and lifestyle factors.

Baback Roshanravan et al. Am J kidney Dis. 2017 Jun. Patients with chronic kidney
disease experience substantial loss of muscle mass, weakness, and poor physical
performance. As kidney disease progresses, skeletal muscle dysfunction forms a
common pathway formobility limitation, loss of functional independence, and
vulnerability to disease complications.

Kristen L Johansen Patients with chronic kidney disease (CKD) are inactive and have
reduced physical functioning and performance. Aerobic exercise interventions have
been shown to increase maximal oxygen consumption in selected patients.

SYMPTOMS ASSOSIATED WITH CKD-

Seerapani Gopaluni et al. Cochrane Database Syst Rev. 2016 Restless legs
syndrome is defined as the spontaneous movement of the limbs(mainly legs)
associated with unpleasant, sometimes painful sensation which is relieved by moving
the affected limb. Prevalence of RLS among people on dialysis have estimated between
6.6% and 80%.

According to Seyed Mehrdad Hamrahian et al. Adv Exp Med Biol.2017-

Hypertension, a global health problem, is currently the leading factor in the global
burden of disease. It is the major modifiable risk factor of heart disease, stroke and
kidney failure.

Shirin Mohammadi-Kalaveh et al. West J Nurs Res. 2018 May said that depression
is the most frequent psychological problem reported among chronic kidney disease
patient being treated by hemodialysis.

TYPE OF EXERCISES-

ACCORDING TO Franklin C. Barcellos -his study aim was to search for and evidence
on effectiveness of exercises in CKD patients. A systematic review was done of
randamozied clinical trials.

Measures of physical fittnes,such as oxygen peak consumption. On average, aerobic

exercise lasting from 8 weeks to 6 months improved vo2 peak-20%
Muscular strength- some RCTs was given resistance training or aerobic and resistance
training. Mallamaci et al. assess lower limb strength on the patients undergoing
hemodialysis and the muscular strength increases 28%

And yoga based study also showed an improvement of 15% in muscle strength.

Depression was also analysed in CKD patients and has given aerobic exercises. And
the exercises has decreasesd depression scores as well. The Beck depression score
was decreased 34.5% in the Kouidi et al. trial and 39.4% in Ozouni et al.

His study find out a positive effects of aerobic exercises on physical fitness, muscular
strength and quality of life of CKD patients.

Irfan Moinuddin, David J.Leehey studied a comparison of aerobic exercises and

resistance training in patients suffering from or not suffering chronic kidney disease.

And found out that aerobic exercise in CKD patients helps to enhance insulin sensitivity,
increase strength, improve quality of life.

Resistance training in CKD patients increases the muscle strength, and increase the
physical function of the patient.

And also combined aerobic exercise and resistance training at the time of dialysis
improves muscle strength, cardiac fitness, work output and quality of life of a patient.

Koji Hiraki et al. study said that home based exercise program for the pre-dialysis CKD
patients was feasible and helps to improve the muscle strength of arm ands leg without
affecting the function of kidney.

More studies also stated- CKD is a progressive condition that adversely affects
musculoskeletal health. Secondary, sarcopeniadue to CKD is associated with
malnutrition, osteoporosis, mobility limitations and elevated fall risk.

Physical therapy constitutes an important element of the plan of care for individuals
with CKD. Strength training remains an important part of the comphrensive
management of CKD. However, great involvement from the health care team is needed
to provide a formal exercise prescription and monitor program effectiveness.

Exercise has beneficial effects on systemic inflammation, muscle, and physical

performance in chronic kidney disease. Exercise rehabilitation programmes, combining
lifestyle education and exercise, have the potential to promote habitual exercise by
increasing physical activity.

Recent evidence has suggested that patients have significantly decreased physical
activity. Based on this, it is now recommended to regularly improve the physical activity
of these patients. Furthermore, studies have also shown the beneficial effects of various
exercise programmes with respect to outcomes such as low physical activity, quality of
life and cardiovascular outcomes. The number of patients with CKD worldwide is rising
markedly becoming a priority public health problem. Rehabilitation is effective and
efficient in reducing the burden of disability and enhancing activities and participation for
disabled people.

ACCORDING TO Johansen KL, with 66 publications, followed by Smith AC,

Painter P, Sakkas GK and Ikizler TA- chronic kidney disease(CKD) is a progressive
disorder, which can lead to end-stage renal disease(ESRD), and requires renal
replacement therapy, including dialysis or kidney transplant. Patients at different stages
of CKD experience substantial burdens, including cardiovascular injury, exercise
tolerance, physical/psychological fatigue, and poor health related quality of life.

Exercise training or comprehensive multi-dimensional strategy and goal-oriented

intervention should be provided in CKD and ESRD subjects according to clinical
condition and functional impairments. Since severe CKD/ESRD disabled subjects
present complex dysfunction, goals and expected outcomes of treatment should be
discussed with the patient and caregiver. Structured prevention programs based on
reducing the risk factors for CKD and rehabilitative strategies could reduce disability
occurrence and related social cost.

Baris Afsar 1, Dimitrie Siriopol 2, Gamze Aslan 3, Ozgur C Eren 4, Tuncay JAN
17,2018- The prevalence of CKD, and end-stage renal disease is increasing steadily.
CKD does not only relate to morbidity and mortality but also has impact on quality of life,
depression and malnutrition. Such patients often have significantly decreased physical
activity.

The Kidney Disease Improving Global Outcomes (KDIGO) 2012 clinical practice
guideline and other guidelines recommended to increase physical activity levels.

In 2013 and 2014, both the Exercise and Sports Science Australia position statement
and the American Colleges of Sports Medicine guideline recommended aerobic,
resistance, and flexibility exercises in CKD patients.

Based on current evidence, the guidelines for managing CKD by the Japanese Society
of Renal Rehabilitation (JSRR) identify renal rehabilitation as an effective and safe
intervention.
In November 2016, an international group of researchers and clinicians met in Chicago
as the Global Renal Exercise (GREX) Working Group to discuss research priorities
related to exercise in CKD

CONCLUSION-

Saulo Freitas da Silva et al. J Bras Nefrol. Jul-Sep 2013- Physical therapy, through
an exercise program during the intradialytic period, can provided a significant
improvement of QOL and physical ability of patients with CKD.

Antonia Kaltsatou et al. J Bodyw Mov Ther. 2015 Jul. systematic exercise training
seems to improve cognitive function in chronic kidney disease patients but further
research is warranted to further clarify the mechanism involved.

Nihal Aydemir et al. Nutr Metab Cardiovasc Dis. 2020 dietry caloricrestriction
increase plasma adiponectin levels in stage 3-4 patients, with limited effect on leptin
levels. These findings suggest the potential for improving the metabolic milieu of CKD
with moderate calorie restriction.

Ryohei Yamamoto et al. J Nephrol. 2021 Feb-aerobic exercise of 3-12 months

duration improved obesity, high blood pressure and low exercise capacity in
overweight/obese patients with CKD, but it had no significant effect on GFR and
proteinurea. Well designed large RCTs with a longer follow up period are needed to
evaluate the efficacy of aerobic exercise in patients with CKD.

Henry H L Wu et al. Int Urol Nephrol. 2021 Nov. Patients with advanced CKD and
severe frailty have a high mortality risk following hip fracture.

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