Part1: Effects Of Different Types Of Exercise On Kidney Diseases

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Abstract: The effects of exercise on kidney function have been studied for more than three decades. One of the most common health issues among patients with chronic kidney disease(CKD)is a lack of physical activity, which leads to a low exercise capacity in these patients. The majority of maintenance hemodialysis (MHD) patients do not exercise at all. At each stage of dialysis, patients lose 10-12g of their amino acids through blood sampling. Dialysis also leads to increased cortisol and circadian rhythm sleep disorders in hemodialysis (HD)patients. Studies have also reported higher C-reactive protein levels in HD patients, which causes arterial stiffness. Exercise has a variety of health benefits for these patients, including improved blood pressure control, better sleep, higher physical function, and reduced anxiety and depression. On the other hand, it should be noted that intense exercise has the potential to progress KD, especially when conducted in hot weather with dehydration. This review aimed to investigate the effects of different types of exercise on kidney disease and provide exercise guidelines. In conclusion, moderate-intensity and long-term exercise(for at least 6 months), with consideration of the principles of exercise (individualization, intensity, time, etc.), can be used as an adjunctive treatment strategy in patients undergoing dialysis or kidney transplantation.

Keywords: aerobic exercise; resistance exercise; electrical muscle stimulation; kidney disease

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1. Introduction

Chronic kidney disease(CKD) is a general term used for various disorders in the structure and function of the kidney. CKD is one of the leading causes of morbidity and mortality, with a global estimated prevalence of 13%(11-15%)[1]. A decline in the estimated glomerular filtration rate (eGFR) is a major indicator of kidney disease [2]. The normal range of GFR， adjusted for body surface area， is 125 mL/min/1.73 m² in men. In CKD， the eGFR is reduced to less than 60 mL/min per 1.73 m². The most severe form of this disease is end-stage kidney disease (ESKD), during which the GFR drops to less than 15 mL/min per 1.73 m²， a stage at which dialysis or a kidney transplant is required to maintain the patient's normal life [5,6]. CKD presents a variety of symptoms, including circadian rhythm sleep disorders, cardiovascular problems, a severe decrease in muscle mass, a decrease in antioxidant capacity, the disruption of the redox balance, and high blood pressure [2,6-8].

Lifestyle changes, the most important of which is exercise, are among the main strategies for the prevention and treatment of CKD, such as pharmacological approaches, dietary improvements, and antihypertensive drugs. Exercise has been recognized as a fundamental component for enhancing or maintaining overall health and wellness; improving physical function; and preventing and curing various diseases, namely reducing the risk of cardiovascular events and mortality [9] and possibly providing multiple benefits to CKD patients [2,4,10]. What is certain is that exercise affects the body's various systems by altering the blood flow and metabolism, improving the body's ability to utilize oxygen, and increasing the demand for nutrients [7,9,10]. Kidneys and collecting ducts, muscles, and the cardiorespiratory system are among the body organs that change the way they work due to exercise [7,1112]. Exercise and physical activity lead to changes in kidney hemodynamics and electrolytes [7,10,13]. Several studies have shown that exercise can improve eGFR and kidney function [4,6,13]. Toyama et al. investigated whether exercise therapy has the potential to modify lipid metabolism and improve the eGFR in patients with cardiovascular disease and CKD[14]. Furthermore, a meta-analysis confirmed that the eGFR was increased by 2.62mL/min/1.73 m² after exercise therapy in non-dialysis CKD patients. A systematic review reported that aerobic and/or resistance training has significant positive effects on physical and functional capacity in non-dialysis CKD[16]. Hypertension, diabetes, and obesity are the risk factors that increase the incidence of CKD[15]. According to a meta-analysis, exercise therapy has anti-hypertensive effects, reducing both systolic and diastolic blood pressure (BP) in CKD patients[15].In a study by Alike et al., aerobic training improved BP in overweight non-dialysis-dependent CKD patients [17]. Contrarily, a lack of an impact of exercise on BP in CKD patients has been reported [14,18], which may be related to the type or intensity of exercise performed. During exercise, the effective renal blood flow(RBF) decreases, the degree of which is directly related to the intensity of exercise and sometimes reaches 25% of the resting value during strenuous exercise [6]. The potential health benefits of moderate-intensity exercise in reducing insulin resistance, metabolic syndrome, and chronic diseases are well-known[19]. Although moderate-intensity exercise is safe, high-intensity exercise may increase biomarkers indicative of muscle and kidney damage, namely serum creatine kinase(CK) and urine myoglobin and creatinine levels[19,20]. On the contrary, it was shown that HIT is practical and safe for CKD patients, with similar benefits to HIIT and MICT on exercise capacity and skeletal muscle protein synthesis [21].

Now, considering the dual role of exercise in health, this study aims to investigate the feasibility and potential benefits of different types of exercise in CKD patients. The investigation of the effects of various types of exercise on physical function and different health aspects in patients with different kidney diseases is clinically important because there are distinctions between kidney diseases.

2. Materials and Methods

PubMed and Google Scholar were electronically searched for papers that were published in English. The search strategy included different combinations of the terms"CKD"and"ESRD"with exercise intervention terms such as"exercise","aerobic exercise","resistance exercise","combined exercise","exercise with blood flow restriction","physical activity","functional exercise","electrical muscle stimulation", or"high-intensity interval training(HIT). Inclusion criteria were clinical trial studies and randomized and controlled clinical trials. Only full-text articles were selected. The searching procedure was performed by two independent authors (M.M.and A.F.). Upon the occurrence of any possible disagreements as to whether a particular study should be considered in the study, the opinion of the supervising professor was asked. The next step was to read the full text of the considered studies. A total of 166 articles were found with the above criteria, and after the screening, 39 of them were examined: a total of 18 for aerobic exercise interventions,7 for resistance exercise, 5 for combined exercise,3 for exercise with blood flow restriction, 3 for electrical muscle stimulation,2 for HIT, and 1 for functional exercise. Exclusion criteria included studies that used a combination of nutritional and exercise interventions and drug and exercise interventions and estimation methods. A total of 1449 patients with CKD in the early stages of ESRD and patients with kidney transplantation were included in this study. Most of the applied interventions were intradialytic, and some were home-based exercises. Moreover, resistance exercises in these studies were performed using elastic bands. We excluded animal studies; furthermore, most of the human studies were carried out on adults. See Figure 1.

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