|Year : 2016 | Volume
| Issue : 3 | Page : 97-105
Effect of moderate aerobic exercises on kidney function and lipid profile in chronic kidney disease patients
Awney F Rahmy1, Walid M Afifi MSc, MD 2, Adel A.M. Ghorab2, Hatim A Mostafa3
1 Department of Cardiovascular/Respiratory Disorder and Geriatrics, Faculty of Physical Therapy, Cairo University, Cairo, Egypt
2 Nephrology Unit, Department of Internal Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt
3 Department of Clinical Pathology, National Liver Institute, Menofiya University, Menofiya, Egypt
|Date of Submission||10-Feb-2016|
|Date of Acceptance||03-Aug-2016|
|Date of Web Publication||2-Jan-2017|
Walid M Afifi
Nephrology Unit, Department of Internal Medicine, Faculty of Medicine, Zagazig University, P.O.BOX 54150, Jeddah 21514 KSA, Zagazig
Source of Support: None, Conflict of Interest: None
Chronic kidney disease (CKD) is an important risk factor for cardiovascular diseases and mortality. Physical inactivity is a modifiable risk factor that may affect the development and course of CKD. It is well established that exercise improves a number of metabolic factors, as well as blood pressure and insulin resistance, which would be expected to preserve renal function and lower cardiovascular risks.
Aim of the study
The aim of this study was to investigate the effect of treadmill walking exercise (moderate aerobic exercise) on kidney function tests and lipid profile in patients with CKD stages 3 and 4.
Patients and methods
Fifty patients with CKD stages 3 and 4 participated in the study. They were selected from the outpatient clinic of Nephrology Department, Zagazig University Hospitals (during the period from January 2015 to June 2015). Their ages ranged from 45 to 55 years. They were divided into two groups: the study group (group B), which included 30 patients who received moderate aerobic exercises on treadmill three times per week for 3 months plus their medications, and the control group (group A), which comprised 20 patients who received their medications only with no training exercises. Urine and blood samples were collected for determining glomerular filtration rate (GFR), serum blood urea, serum creatinine, and serum lipid profile before the initiation of the training program and after the completion of the study (after 3 months).
There was a statistically highly significant decrease in creatinine, blood urea, triglyceride (TG), cholesterol, and low-density lipoprotein (LDL), and an increase in GFR and high-density lipoprotein (HDL) (P<0.001) in group B after treatment compared with the pretreatment values with the following percent of improvement: creatinine −11.5%, blood urea −7.9%, TG −10.5%, cholesterol −13.1%, LDL −11.9%, GFR +17.4%, and HDL +12.6%. However, there were no significant differences between pretreatment and post-treatment values of creatinine, blood urea, or GFR in group A. There was a significant decrease in TG, cholesterol, and LDL, and a significant increase in HDL in group A after 3 months, with the following percent of improvement: TG −2.9%, cholesterol −3.4%, LDL −5.6%, and HDL +6.7%. There was a statistically significant difference in the post-treatment values of all parameters between the two groups.
It can be concluded that moderate aerobic exercises improve kidney function tests and lipid profile and can delay progression of CKD stages 3 and 4.
Keywords: chronic kidney disease, kidney function tests, moderate aerobic exercises
|How to cite this article:|
Rahmy AF, Afifi WM, Ghorab AA, Mostafa HA. Effect of moderate aerobic exercises on kidney function and lipid profile in chronic kidney disease patients. J Egypt Soc Nephrol Transplant 2016;16:97-105
|How to cite this URL:|
Rahmy AF, Afifi WM, Ghorab AA, Mostafa HA. Effect of moderate aerobic exercises on kidney function and lipid profile in chronic kidney disease patients. J Egypt Soc Nephrol Transplant [serial online] 2016 [cited 2018 Sep 22];16:97-105. Available from: http://www.jesnt.eg.net/text.asp?2016/16/3/97/197383
| Introduction|| |
Chronic kidney disease (CKD) guidelines shifted the concept of kidney disease from that of an uncommon life-threatening condition requiring care by nephrologists to that of a common condition with a range of severity meriting attention by general internists, and demanding strategies for prevention, early detection, and management .
Although much has been written about exercise tolerance and exercise training for patients on dialysis therapy, individuals with non-dialysis-dependent CKD have been relatively understudied, perhaps because of the heterogeneity of the CKD population. Although it is well established that patients on dialysis therapy are limited in their physical activity, the question of whether and to what extent patients with CKD are limited is more difficult to address because the result may vary depending on the stage of the disease .
Decreased kidney function refers to a decreased glomerular filtration rate (GFR), which is usually estimated (eGFR) using serum creatinine as one of the several available equations. The various GFR estimating equations use serum creatinine along with some combinations of age, sex, and race and body size as surrogates for the non-GFR determinants of serum creatinine, and provide more accurate estimates of measured GFR compared with serum creatinine alone. The Modification of Diet in Renal Disease (MDRD) study equation is the most frequently used GFR estimating equation in the USA ,.
There are several reasons why individuals suffering from CKD frequently lose fitness and have a hard time performing daily tasks. However, new research shows evidence that individuals with the disease, including those with a kidney transplant, who take part in regular physical activity can benefit from improved physical fitness, healthier blood pressure, walking a longer distance, healthier heart rates, better nutritional characteristics, and higher health-related quality of life, in comparison with individuals who do not engage in physical activity ,.
Increased physical activity is associated with better survival in the general population. A previous analysis of the MDRD study suggested that higher levels of physical activity were not significantly associated with reduced mortality in the CKD population .
Exercise training appears to be an important intervention in protecting against chronic diseases such as diabetes mellitus, end-stage renal disease (ESRD), and heart failure. Public health physical activity recommendations state that moderate-intensity aerobic physical activity for a minimum of 30 min, at least 5 days each week, confers substantial protection against chronic diseases ,.
Dyslipidemia including increased total cholesterol, triglycerides (TG), and low-density lipoprotein cholesterol (LDL-C) concentrations and decreased high-density lipoprotein cholesterol (HDL-C) is one of the risk factors implicated in increased cardiovascular risk associated with CKD and also in the progression of renal damage. Therefore, early identification and proper management not only of CKD but also of dyslipidemia can prevent the progression of ESRD and the development of associated morbidities, including cardiovascular disease .
| Patients and methods|| |
The study was approved by the Scientific and Ethical committees at ZAGAZIG Faculty of Medicine. And informed consent was obtained from all participants. Fifty patients with CKD stages (3 and 4) participated in this study, during the period from January 2015 to June 2015. Their ages ranged from 45 to 55 years. They were selected from the outpatient clinic of Nephrology Unit, Zagazig University Hospitals. The study was conducted in the outpatient clinic of the Physical Therapy Department in Zagazig University Hospitals. Both sexes were included.
All patients were examined by the responsible physician to exclude the following criteria:
- Severe chronic cardiac problems.
- Chronic chest disease.
- Chronic inflammatory orthopedic disorders and rheumatoid arthritis.
- Psychological or mental impairments.
- Severe obesity (BMI>38).
- Neurological dysfunction.
- All of the patients did not receive any physical therapy programs before sharing in the study.
The patients were assigned into two groups: the control group (group A), which included 20 patients (11 male and nine female) who received no training but received medical treatment, and the study group (group B), which included 30 patients (18 male and 12 female) who received walking exercise on electronic treadmill plus medical treatment. The study group was trained for 12 weeks, three times a week. All patients received a thorough explanation of the procedures and duration before starting the study. A written consent form was obtained from each patient before including in the study.
All patients tolerated and completed the study and underwent the following evaluation steps: preliminary assessment, anthropometric measures, laboratory investigations, and training procedures.
Careful medical history of each patient was taken, including name, age, race, weight, height, address, medications, etc.
Heart rate, respiratory rate, blood pressure, and temperature were examined before and after each session to exclude any signs or symptoms that may interfere with the continuity of the study and to detect maximal heart rate.
The patient’s weight and height were measured using weight and height scale to determine BMI; the patient was required to wear light clothes and be in bare feet.
Measurement of blood urea nitrogen, creatinine, and blood lipids (cholesterol, TG, LDL, and HDL) was carried out before the initiation of the training program and after the completion of the study (i.e. after 3 months).
Before starting, a thorough explanation was given for each participant individually; the participant was required to wear light clothes and well-fitted shoes comfortable for walking and running on treadmill. The participant was seated comfortably, allowing the feet to be rested on the ground. The participant was allowed to rest in that position for 10 min to gain hemodynamic stabilization. The vital signs were recorded with the patient in resting position, such as pulse rate, respiratory rate, and blood pressure, before exercise.
Exercise session for the study group
- Warm-up phase: The patient started the exercise session with warm-up exercise at a speed of 0.5 mph for 5 min to allow for conditioning of the body for the exercise. Thereafter, the speed was increased to 2 mph for 3 min, after that the speed was increased in increments of 1.0 mph every 2 min until the participant reached level 14–75% effort of Borg scale effort.
- Training phase: The patient walked at the level of speed obtained when he or she reached level 14–75% effort of Borg scale effort (somewhat hard) for 15–20 min.
- Cooling down phase: Afterward, the speed was decreased to 0.5 mph and the session was terminated with cooling down for 5 min as warming up.
Enraf nonius motor-driven treadmill, made in Holland, was used for treadmill walking exercise for the study group. It has the following features:
- Speed control: The ▾ and ▴ keys can decrease or increase the treadmill’s speed. The range of speed is from 0.5 to 152 mph.
- Time display: It displays the time that has elapsed since beginning a specified program.
- Distance display: It shows the distance that has been covered during the workout. Distance can appear in miles or kilometers.
- Calories display: It provides the cumulative number of calories burned in the workout.
- Heart rate monitor: Heart rate is shown as beats/min. It is used to monitor one’s heart rate and is displayed when contact is made with the thumb to the thumb pulse button (thumb sensor).
The Borg scale (Borg 1982) is a simple method of rating perceived exertion (RPE).
Types of scales
There are a number of RPE scales but the most common ones are the 15-point scale (6–20) and the 11-point scale (0–10).
- 6–20% effort.
- 7–30% effort: very, very light (rest).
- 8–40% effort.
- 9–50% effort: very light – gentle walking.
- 10–55% effort.
- 11–60% effort: fairly light.
- 12–65% effort.
- 13–70% effort: somewhat hard, steady pace.
- 14–75% effort.
- 15–80% effort: hard.
- 16–85% effort.
- 17–90% effort: very hard.
- 18–95% effort.
- 19–100% effort: very, very hard.
All data were coded, checked, entered, and analyzed using SPSS statistical software, version 17 (SPSS Inc., Chicago, Illinois, USA); variables are described as means and SDs. The χ2-test was used.
A P-value less than 0.05 was considered statistically significant.
| Results|| |
There was no significant difference between the two groups in their ages, weights, heights, and BMI, and their t and P-values were as follows: 0.95, 0.34; 1.67, 0.1; 0.6, 0.55; and 1.14, 0.26, respectively ([Table 1]).
[Table 2] presents the independent t-test results for the blood urea nitrogen (BUN) before and after treatment between groups A and B. There was no significant difference in the pretreatment values; t-value was 0.97 and P-value was 0.33. However, there was a significant difference in the post-treatment values; t-value was 2.95 and P-value was 0.005.
|Table 2 Independent t-test between groups A and B for BUN before and after treatment|
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[Table 3] presents the independent t-test results for serum creatinine before and after treatment between groups A and B. There was no significant difference in the pretreatment values; the t-value was 0.67 and P-value was 0.5. However, there was a significant difference in the post-treatment values; the t-value was 2.25 and P-value was 0.02.
|Table 3 Independent t-test between groups A and B for serum creatinine before and after treatment|
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[Table 4] presents the independent t-test results for GFR (MDRD) before and after treatment between groups A and B. There was no significant difference in the pretreatment values; the t-value was 0.36 and P-value was 0.71. However, there was a significant difference in the post-treatment values; the t-value was 2.18 and P-value was 0.03.
|Table 4 Independent t-test between groups A and B for GFR MDRD before and after treatment|
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[Table 5] presents the independent t-test results for cholesterol before and after treatment between groups A and B. There was no significant difference in the pretreatment values; the t-value was 0.28 and P-value was 0.77. However, there was a significant difference in the post-treatment values; the t-value was 2.25 and P-value was 0.02.
|Table 5 Independent t-test between groups A and B for total cholesterol before and after treatment|
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[Table 6] presents the independent t-test results for LDL before and after treatment between groups A and B. There was no significant difference in the pretreatment values; the t-value was 0.84 and P-value was 0.4. However, there was a significant difference in the post-treatment values; the t-value was 2.3 and P-value was 0.02.
|Table 6 Independent t-test between groups A and B for LDL before and after treatment|
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[Table 7] presents the independent t-test results for HDL before and after treatment between groups A and B. There was no significant difference in the pretreatment value; the t-value was 0.28 and P-value was 0.8. However, there was a significant difference in the post-treatment values; the t-value was 2.3 and P-value was 0.02.
|Table 7 Independent t-test between groups A and B for HDL before and after treatment|
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[Table 8] presents the independent t-test results for TG before and after treatment between groups A and B. There was no significant difference in the pretreatment values; the t-value was 0.28 and P-value was 0.8. However, there was a significant difference in the post-treatment values; the t-value was 2.3 and P-value was 0.02.
|Table 8 Independent t-test between groups A and B for TG before and after treatment|
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[Table 9] shows the comparison between the percentages of changes in BUN, creatinine, GFR, and cholesterol, TG, LDL, and HDL in both groups before and after the treatment period; there was a significant difference between groups A and B.
|Table 9 Comparison between the percentages of improvement in both groups|
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| Discussion|| |
This study evaluated the effect of moderate aerobic exercise on kidney function and lipid profile in the CKD patient in stages 3 and 4. The aerobic walking exercise was performed using a motorized treadmill.
The benefits of exercise training in the current study were prospective and generalized, reflecting on many aspects. First, after adherence of patients to the current study, they were encouraged and motivated to participate in a regular exercise program as they have physically touched the benefits of exercises in the form of overall improvement in the performance of ordinary activities of daily living, which may be affected from the disease. This functional improvement occurred by increasing circulatory capacity and aerobic fitness that assist patients to maintain normal activities. Second, the psychological status of the participant has been improved resulting in more independence, more social interaction, and more activities. Finally, in sequence from all of the above, the quality of life and well-being of patient have been enhanced in great aspect.
The benefits of physical exercise are well described in the general population and in long-term conditions such as chronic obstructive pulmonary disease, which, similar to CKD, are associated with progressive deconditioning due to a downward spiral of inactivity and muscle wasting. In CKD, this scenario is further aggravated by the catabolic effects of uremia and acidosis. The benefits of exercise in kidney disease have been best described in patients on regular hemodialysis undertaking intradialytic aerobic exercise, usually static cycling .
CKD is defined as the presence of kidney damage, manifested by abnormal albumin excretion or decreased kidney function, quantified by measured or eGFR that persists for more than 3 months. The purpose of CKD staging is to guide management, including stratification of risk for progression and complications of CKD: stage 1, normal eGFR 90 ml/min/1.73 m2 and persistent albuminuria; stage 2, eGFR between 60 and 89 ml/min/1.73 m2; stage 3, eGFR between 30 and 59 ml/min/1.73 m2; stage 4, eGFR between 15 and 29 ml/min/1.73 m2; and stage 5, eGFR less than 15 ml/min/1.73 m2 or ESRD .
The general belief among nephrologists was that patients with CKD were not able to perform exercise training, that it was impossible for them to increase their aerobic capacity, and that the strong catabolic force of uremia prevented any exercise-induced effects on muscle strength, endurance, or volume status .
The era of erythropoietin-stimulating agents has undoubtedly been helpful in facilitating exercise training for patients suffering from CKD, as it creates a reasonable amount of oxygen-bearing capacity, doing away with the most extreme levels of fatigue and inertia. Research has shown beyond doubt that all patients with CKD benefit from exercise training, including the elderly, the young, and those with considerable functional impairment, irrespective of the stage of CKD and treatment modality .
In the general population, level of physical activity is strongly related to overall survival, decreasing death from any cause .
Stack and colleagues (2005) has shown that patients with CKD are no different. Self-reported levels of physical activity is low in the majority of patients starting on maintenance dialysis − in fact, about 60% engage in no form of weekly physical activity at all .
Rigorous aerobic exercise training in a group of hemodialysis patients over a period of 9 months showed significantly positive effects on cardiac status, including a decrease in left ventricular mass index and an increase in cardiac output index and ejection fraction, higher scores for heart-rate variability index, and lower frequency of arrhythmias .
Levels of blood pressure improve and the number of antihypertensive agents needed to control blood pressure decreases after aerobic exercise training .
During the course of CKD, patients show a gradual decline in maximal exercise capacity correlated with the loss of renal function. With time, in patients on maintenance dialysis, maximal exercise capacity decreased to about 50–60% of the expected .
At CKD stage 3, patients have started to lose muscle mass and show increasing atrophy of the thigh muscle as renal function continues to decrease .
The percentage of improvement in our study as regards kidney functions and lipid profile are very important in protection against cardiovascular risk factor in CKD patients and can be recommended in treatment plan.
In addition, the study participants demonstrated a high level of compliance with the exercise program proposed, suggesting that a high level of adherence can be achieved in a chosen aerobic exercise activity. Walking is an easily accessible exercise method that is associated with the activities of daily living, low in cost, and promotes an improvement in socialization.
The results of the current study may be due to the observation that training associated with muscle hypertrophy in patients in CKD stages 3 and 4 has been shown to reduce inflammatory status by lowering serum levels of C-reactive protein (CRP) and interleukin-6 and increasing levels of serum transferring .
Serum CRP decreased within 12 days in young and elderly women who had completed 12 weeks of physical exercise .
Exercise has both short-term and long-term beneficial effects on metabolism in nondiabetic individuals. In controlled trials, moderate physical activity improves fasting and postprandial glucose–insulin homeostasis, induces and maintains weight loss, raises HDL-C, lowers LDL-C and TG, lowers blood pressure, and probably lowers inflammation and improves endothelial function .
Moreover, aerobic exercise improved arterial stiffness, an effect that had reversed by 1 month after training had ceased . This reduced arterial stiffness may also explain the improved GFR after aerobic exercise in our patients.
Long-term aerobic exercise has been associated with better arterial compliance, and antidiabetic and anti-inflammatory benefits. It was hypothesized that in patients with diabetes and CKD, better aerobic capacity is associated with less inflammatory state and arterial stiffness .
Voluntary aerobic exercise reverses arterial inflammation with aging in mice. This may be mediated in part through the inhibition of macrophage infiltration of perivascular tissue and arterial adventitia. These anti-inflammatory actions may play an important role in the beneficial effects of voluntary aerobic exercise on vascular function observed in middle-aged and older adults .
Oxidative stress is another potential mediator in the association between physical activity and kidney function decline, and could help explain our finding of a persistent association after adjustment for markers of hypertension and inflammation. Oxidative stress is both a cause and a consequence of hypertension and is present in patients with mild-to-moderate renal insufficiency, as well as in those with ESRD receiving dialytic therapies. Hypertension and oxidative stress improve within 3 weeks of moderate physical activity and the consumption of a diet low in fat and sugar and rich in natural antioxidants ,.
Sex-specific risk factors for the change in kidney function in a nondiabetic Norwegian population were evaluated. In age-adjusted analysis, lesser physical activity was associated with a greater increase in the serum creatinine level over time among women. However, these associations did not persist after adjustment in either sex. One possibility is that previous studies of physical activity are hampered by the use of serum creatinine levels to estimate kidney function. As exercise may increase muscle mass, or limit the decline in muscle mass that occurs with inactivity, potential benefits of exercise on kidney function may be obscured by a concomitant rise in the serum creatinine level .
There were significant benefits of the exercise regimen: improved exercise tolerance as judged by falling RPE scores for the same achieved exercise and broad improvements in the quality of life and health. The quality of life improvements are of interest in view of evidence that the psychological benefits of exercise may be an important contributor to the accompanying physical improvements in health .
With regard to renal function, previous studies have shown that a single exercise session may alter renal hemodynamics due to an increase in blood flow, which activates muscles and promotes an increase in intraglomerular pressure. Therefore, an increase in efferent arteriole pressures after exercise is thought to cause an increase in hydraulic pressures and facilitate the passage of proteins throughout the glomerulus .
These significant differences in the post-treatment values of BUN, creatinine, and GFR between the two groups are in agreement with the nonrandomized study of Pechter et al. , who reported a significant decrease in proteinuria and cystatin C level as well as improvements in GFR.
Our results are also in agreement with those of Robinson et al. , who said that the positive effects of a high level of physical activity on the progression of uremia has been reported in older adults, wherein patients with high activity scores had 28% lower risk for rapid decline in kidney function, defined as the loss of more than 3.0 ml/min/1.73 m2 per year in GFR.Our results are in agreement with those obtained by Tomiyama and colleagues (2010), who assigned 10 patients with CKD to exercise for 12 weeks and nine patients to a nonexercising control group. BUN and creatinine had been decreased; the anaerobic metabolic threshold, HDL-C level, and eGFR were increased in the exercise group; and the change in eGFR correlated with the change in anaerobic metabolic threshold and HDL-C level .
Our results are contradictory to those of Leehey et al. , who reported that aerobic exercise training did not significantly alter BUN, creatinine, GFR, hemoglobin, serum lipid, or CRP values, but power was limited because only seven patients in the exercise group and four patients in the control group finished the study.
Exercise is beneficial in ameliorating cardiovascular risk factors such as hypertension, dyslipidemia, hyperglycemia, obesity, inflammation, and oxidative stress. Moreover, it has been reported that inactivity is associated with the development of major CKD precursors, including albuminuria, reduced GFR, and initiates diabetes .
Not only could exercise slow the progression from CKD to ESRD, but it could also improve the quality of life and survival of patients with ESRD .
Although there are still no large randomized controlled trials evaluating the survival benefits of exercise, the evidence reviewed above justifies that the regular use of exercise programs in patients with advanced CKD could reduce the rate of progression of renal impairment.
No study has reported worsening of kidney function as a result of exercise training. In the absence of guidelines specific to the CKD population, recent guidelines developed for older individuals and patients with chronic disease should be applied to the CKD population. In sum, exercise appears to be safe in this patient population if begun at moderate intensity and increased gradually. Indeed, the evidence suggested that the risk of remaining inactive is higher. Patients should be advised to increase their physical activity when possible and referred to physical therapy or cardiac rehabilitation programs when appropriate.
The correlation of increased mortality with low physical activity, low muscle mass, and reduced physical functioning provides a clear rationale for exercise in CKD patients.
It should be emphasized that the most frail and incapacitated patients are probably those most in need of physical rehabilitation as a part of their clinical care.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rettig RA, Norris AR. Chronic kidney disease in the United States: a public policy imperative. Clin J Am Soc Nephrol 2008; 3:1902.
Painter P. Physical functioning in end-stage renal disease patients: update2005. Hemodial Int 2005; 9:218–235.
Stevens LA, Coresh J, Feldman HI. Evaluation of the modification of diet in renal disease study equation in a large diverse population. J Am Soc Nephrol 2007; 18:2749.
Stevens LA, Levey AS. Measured GFR as a confirmatory test for estimated GFR. J Am Soc Nephrol 2009; 20:2305.
Johansen KL. Exercise in the end-stage renal disease population. J Am Soc Nephrol 2007; 18:1845–1854.
Johansen KL, Painter P. Exercise in Individuals with CKD. Am J Kidney Dis 2011; 59(1): 126–134.
Ikizler T. Nutrition and kidney disease. Primer on kidney diseases. Philadelphia: Elsevier Saunders 2005. 495–501
Haskell WL, Lee IM, Pate RR. Physical activity and public health: updated recommendation from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc 2007; 39:1423–1434.
Winnick JJ, Sherman WM, Habash DL, Stout MB, Failla ML. Short-term aerobic exercise training in obese humans with type 2 diabetes mellitus improves whole-body insulin sensitivity through gains in peripheral, not hepatic insulin sensitivity. J Clin Endocrinol Metab 2008; 93:771–778.
Kim S, Lim CS, Han DC, Kim GS, Chin HJ, Kim SJ et al.
The prevalence of chronic kidney disease and the associated factors to CKD in Urban Korea: a population-based cress-sectional epidemiologic study. J Korean Med Sci 2009; 24:S11–S21.
Cheema B, Singh M. Exercise training in patients receiving maintenance hemodialysis: a systematic review of clinical trials. Am J Nephrol 2007; 25:352–364.
Levey AS, Eckardt KU, Tsukamoto Y. Definition and classification of chronic kidney disease: a position statement from kidney disease: improving global outcomes (KDIGO). Kidney Int 2005; 67:2089–2100.
VanLare JM, Conway PH. Value-based purchasing – national programs to move from volume to value. N Engl J Med 2012; 367:292.
Castaneda C, Gordon PL, Parker RC, Uhlin KL, Roubenoff R, Levey AS. Resistance training to reduce the malnutrition-inflammation complex syndrome of chronic kidney disease. Am J Kidney Dis 2004; 43:607–616.
Paffenbarger RS, Stack AG, Hagren B, Partin AW, Peters CA. Exercise and its role in the prevention and rehabilitation of cardiovascular diseases. N Engl J Med 1997; 328:538–545.
Stack AG, Hagren B, Partin AW, Peters CA. Association of physical activity with mortality in the US dialysis population. Am J Kidney Dis 2005; 45:690–701.
Deligiannis A, Kouidi E, Tourkantonis A. Effects of physical training on heart rate variability in patients on hemodialysis. Am J Cardiol 1999; 84:197–202.
Miller WG. Estimating glomerular filtration rate. Clin Chem Lab Med 2009; 47:1017.
Clyne N, Jogestrand T, Lins L. Progressive decline in renal function induces a gradual decrease in total hemoglobin and exercise capacity. Nephron 1994; 67:322–326.
Foley RN, Parfrey PS, Sarnak MJ. Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis 1998; 32:S112–S119.
Bijlani RL, Vempati RP, Yadav RK, Ray RB, Gupta V, Sharma R. A brief but comprehensive lifestyle education program based on yoga reduces risk factors for cardiovascular disease and diabetes mellitus. J Altern Complement Med 2012; 11:267–274.
Cassianne RC, Katz R, Mozaffarian D, Dalrymple LS, Boer I, Sarnak M et al.
Physical activity and rapid decline in kidney function among older adults. Arch Intern Med 2009; 14:169.
Mustata S, Groeneveld S, Davidson W. Effects of exercise training on physical impairment, arterial stiffness and health-related quality of life in patients with chronic kidney disease: a pilot study. Int Urol Nephrol 2010; 43(4):1133–1141.
Timmerman KL, Flynn MG, Coen PM, Markofski MM, Pence BD. Exercise training-induced lowering of inflammatory (CD14+CD16+) monocytes: a role in the anti-inflammatory influence of exercise? J Leukocyte Biol 2008; 84:1271–1278.
Lesniewski LA, Durrant JR, Connell ML, Henson GD, Black AD, Donato AJ, Douglas R. Is aerobic exercise reverses arterial inflammation with aging in mice? Am J Physiol Heart Circ Physiol 2011; 301:H1025–H1032.
Vaziri ND, Barnard RJ. Effect of diet and exercise intervention on blood pressure, insulin, oxidative stress, and nitric oxide availability. Circulation 2002; 106:2530–2532.
Finkelstein J, Joshi A, Hise MK. Association of physical activity and renal function in subjects with and without metabolic syndrome: a review of the Third National Health and Nutrition Examination Survey (NHANES III). Am J Kidney Dis 2006; 48:372–382.
Crum AJ, Langer EJ. Mind-set matters: exercise and the placebo effect. Psychol Sci 2007; 18:165–171.
Bergamaschi CT, Boim MA, Moura LA, Picarro IC, Schor N. Effects of long-term training on the progression of chronic renal failure in rats. Med Sci Sports Exerc 1997; 29:169–174.
Pechter U, Ots M, Mesikepp S. Beneficial effects of water-based exercise in patients with chronic kidney disease. Int J Rehabil Res 2003; 26:153–156.
Robinson CC, Katz R, Mozaffarian D, Dalrymple LS, de Boer I, Sarnak M et al.
Physical activity and rapid decline in kidney function among older adults. Arch Intern Med 2009; 169:2116–2123.
Tomiyama C, Higa A, Dalboni MA. The impact of traditional and non-traditional risk factors on coronary calcification in pre-dialysis patients. Nephrol Dial Transplant 2010; 21:2464–2471.
Leehey DJ, Moinuddin I, Bast JP. Aerobic exercise in obese diabetic patients with chronic kidney disease: a randomized and controlled pilot study. Cardiovasc Diabetol 2009; 8:62.
Aucella F, Battaglia Y, Bellizzi V, Bolignano D, Cupisti A, Capitanini A. Physical excercise programs in CKD: lights, shades and perspectives. J Nephrol 2015; 28:143–150.
Morishita Y, Nagata D. Strategies to improve physical activity by exercise training in patients with chronic kidney disease. Int J Nephrol Renovasc Dis 2015; 8:19–24.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]