Part3: Effects Of Different Types Of Exercise On Kidney Diseases

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4. Discussion

This review mostly involved studies on patients with ESRD; however, other approaches [2, A-6,12,21,65] were carried out in different stages of kidney disease. There is conflicting evidence on the effect of exercise on the biochemical factors related to kidney function and the exact mechanism by which exercise may be beneficial in CKD patients. That being said, the well-known anti-inflammatory response of exercise could be its most crucial effect in these patients [87l, since kidney inflammation is prevalent in renal in-jury [88], which ultimately causes fibrosis and the everlasting loss of function [89]. The mechanism for the strong anti-inflammatory effect of exercise is visceral fat reduction, which decreases the secretion of pro-inflammatory adipokines [87] and increases levels of anti-inflammatory cytokines (interleukin-6(IL-6), from contracting skeletal muscle)[87]. An increase in lL-6 levels slows the rise in tumor necrosis factor-alpha(TNF-a) levels after exposure to an inflammatory stimulus [90]. The exercise-induced rise in IL-6 and the simultaneous reduction in TNF-a levels propose the potential therapeutic effect of exercise in controlling low-grade inflammation, which can deteriorate CKD[89]. Inflammation, insulin resistance, oxidative stress, and an overactive renin-angiotensin system preserve each other while negatively affecting endothelial and cardiovascular function and health [91]. Exercise improves vascular insulin signaling, raises bioavailable NO, and decreases ROS [1]. At the molecular level, NO production increases due to exercise through a sequence of increasing both NO precursor molecule L-arginine availability and the activity of endothelial synthase(eNOS) and decreasing NO degradation through decreasing ROS [2]. Exercise promotes the endothelial response to insulin by decreasing angiotensin II and other inflammatory molecules such as TNF-α[1]. A wide range of studies support the positive role of aerobic, resistance, and combined training, with BFR, HIT, EMS, and functional training in improving renal function as well as developing the quality of life in patients with KD. Many of the studies examined the effect of different types of exercise on the quality of life and functional capacity of patients with different stages of KD. Most of these studies used TUG,5 STS,30s STS, and 6 MWD as indicators of functional capacity, and most of them confirmed the positive effect of exercise on functional capacity [4,6,27,53,64,65,71,77]. In all of these studies, the STS, as well as the TUG test time, were reduced, and the walking distance was increased within six minutes. Sleep quality was also assessed using the sleep fragmentation index and ADMA. The results showed improvements in the sleep pattern in the exercise group in both studies compared with the control group [35,4]. Exercising with adequate fluid intake reduces the risk of waste product accumulation and decreases the risk of kidney stone formation. Exercise improves peak oxygen consumption in patients and also decreases blood pressure and improves health-related indicators such as lipid profiles and inflammatory indicators as well as psychological indices such as depression and anxiety [92]. 

Studies on blood hemodynamics [2,10,12,13,23,25,77] have used different indices such as flow-mediated vasodilation (FMV), CFPWV, and arterial stiffness(AS).In some studies, refs. [10,12, A44] hemodynamic improvement was demonstrated, but in other studies, no change was observed in FMV, CFPWV, and AS [23,25,78]. Exercise in different stages of KDleads to a temporary change in fecal matter(proteinuria), which returns to a normal level during the recovery period. Exercise during a dialysis session also results in a temporary decrease in blood flow that returns to a normal level during the recovery period. Oxidative stress, pro-inflammation, and malnutrition occurring in CKD lead to the accumulation of metabolic waste products and alterations in homeostasis, which affects many target organs, including the cardiovascular system, and reduces physical capacity, which alters osteoporosis and the loss of muscle mass and ultimately leads to death [93]. Sarcopenia is present from the early stages of CKD and its prevalence rises in the more advanced stages, which is related to higher mortality and disability rates and an increased risk of falls, fractures, and hospitalization [94]. If exercise is designed according to the age range and is individualized for each patient, it will lead to significant improvements. Exercise should be limited in children with chronic renal disease. The only present study, in this case, showed that the exercise load is not tolerable for 70%of children [66]. Therefore, exercise prescription in this group should be considered with caution. There is not sufficient evidence to support the idea of physical activity prohibition in patients with glomerulonephritis, nephrotic syndrome, and kidney transplantation. Given the wide range of studies on the positive role of exercise (aerobic, resistance, and combination) in improving the condition of patients with acute and chronic renal disease, some studies suggest that strenuous exercise, especially when combined with low water intake and in hot weather, can in some cases lead to acute kidney damage and failure (in healthy people)[95]. In intense competitions, the severe rupture of muscle tissue (rhabdomyolysis)releases toxic intracellular components into the systemic circulation, which leads to an overload of renal tubules, heat stress, and intense sympathetic nerve activity due to myoglobin. The potential benefit of aerobic exercise to reduce blood pressure and improve the lipid profile in these patients has been indicated, and it is suggested that the diet should be adjusted along with aerobic exercise. Considering the support of studies on the effect of resistance training on hypertrophy and the strength of different muscle fibers in CKD patients [6,35,3944,46,48,51], resistance training is suggested in patients with kidney disease. Studies have also shown that exercise (aerobic, resistance, etc.) improves glomerular filtration and reduces the risk factors for cardiovascular disease. Several studies have examined redox balance, inflammation index, and total antioxidant capacity [7,11,1235,49]. The results of these studies in the field of antioxidant capacity are ambiguous because this factor was reduced in one study [] but improved in another study[49]. Inflammation markers improved in all of the mentioned studies except the study of Fuhro et al.,[11]. The redox balance improved in all of these studies[7,11,12,35,49]. It seems that the observed improvement in redox status, as well as the reduction in inflammation, is achieved due to the reduction in uremic toxins through increased dialysis efficiency and the excretion of soluble substances. Increased dialysis efficiency was studied by measuring the excretion of soluble substances and the results of the studies proved the increase in excretion of these soluble substances after exercise or an increase in the dialysis time [13,26,33]. On the other hand, some studies indicated that the levels of substances such as albumin and phosphorus do not increase or were maintained, which may be related to the intensity and type of exercise used in the study. In the study of Böhm et al.， no increase in dialysis efficiency was observed. The current exercise guidelines also suggest that people perform stretching exercises for 10 minutes each day and other exercises to develop flexibility. Exercise increases the total antioxidant capacity of the system by affecting transcription factors [96]. It also helps improve blood pressure by increasing the bioavailability of NO and improving the vasoactive balance, as well as reducing the sympathetic activity of vascular smooth muscle [97]. Exercise affects the rate of protein synthesis in muscle by phosphorylating P7056k, thereby reducing the rate of muscle loss and in turn performance in the individual. Finally, according to the results of various studies, it seems that to achieve the benefits of exercise, training should be performed over at least six months. It should also be noted that due to the condition of the parathyroid glands as well as hypogonadism in these patients, conducting any contact sports or exercises with a high workload (excessive repetition)is not recommended [98], because it leads to increased kidney damage in these patients.

5. Conclusions

To sum up, the majority of previous studies showed that:(a) there are beneficial effects of various types of exercise on different kidney diseases, whether during or outside of dialysis session;(b) chronic aerobic, resistance, or combined training, if accompanied by safety considerations, seems to have many benefits for patients with KD, such as improved glomerular filtration, reduced cardiovascular risk factors, increased maximal oxygen uptake, improved muscle protein synthesis, increased or maintained strength, improved body composition, enhanced quality of life, and other health-related factors;(c) the type and stage of kidney disease and the patient's condition should be considered prior to prescribing any exercise program;(d) on the other hand, in CKD patients, exercise prescription should be based on exercise training principles including individualization, specificity, adaptation, recovery, reversibility, and overload; and(e) exercise load is a combination of the frequency, intensity, and duration of the exercise performed and must be considered for any prescription.

References 

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