CKD: Lifestyle Intervention Works

Laurie Barclay, MD

August 23, 2013

A 12-month exercise training and lifestyle intervention in patients with chronic kidney disease (CKD) was linked to better cardiorespiratory fitness (CRF), body composition, and diastolic function, according to findings of a randomized trial published online August 22 in the Clinical Journal of the American Society of Nephrology.

"We were hoping to see that patients became fitter and lost weight and learned techniques that would help them maintain this change," coauthor Nicole Isbel, MD, from Princess Alexandra Hospital and the University of Queensland in Brisbane, Australia, said in a news release.

"We demonstrated that this could be done safely in spite of patients having a number of other health problems. This was in part because of the expertise of the multidisciplinary team, who frequently adjusted diabetic and blood pressure medications."

Between February 2008 and March 2010, 90 patients with stage 3 to 4 CKD underwent an exercise stress echocardiogram, and 83 who passed this screening were assigned to 12 months of standard care (control) or lifestyle intervention. The latter intervention included multidisciplinary care at a CKD clinic by a renal specialist, specialized nurse practitioner, exercise physiologist, dietitian, diabetes nurse, and psychologist. The intervention also included 150 minutes per week of moderate-intensity aerobic and resistance exercise training, as well as group behavior and lifestyle modification sessions.

Outcomes included changes from baseline to 12 months in CRF, as measured by peak oxygen consumption, left ventricular function, arterial stiffness, and anthropometric and biochemical tests.

Of 72 patients who completed follow-up, 36 were in the lifestyle intervention group and 36 in the control group, with no differences at baseline. At screening, 10% of randomized patients had subclinical myocardial ischemia, but they safely completed the study.

Improvements in CRF

Only 45% of participants (41% in the lifestyle group and 47% from the control group) achieved age-predicted exercise capacity at baseline. After 12 months of the intervention, maximal aerobic capacity significantly increased by 11% in those who received the lifestyle intervention compared with a 1% decrease in patients who received usual care. Peak oxygen consumption increased (2.8 ± 0.7 mL/kg per minute) in the intervention group but decreased in controls (−0.3 ±.9 mL/kg per minute; P = .004). The intervention group had small but significant weight loss (−1.8 ± 4.2 kg vs 0.7 ± 3.7 kg; P = .02), but blood pressure and lipid levels were unchanged.

Systolic function was well preserved and stable in the intervention group, whereas diastolic function improved compared with worsening in the control group (increased e′ of 0.75 ± 1.16 cm/second vs −0.47 ± 1.0 cm/second; P = .001) Change in arterial elastance was less pronounced in the intervention group (0.11 ± 0.76 mm Hg/mL) than in the control group (0.76 ± 0.96 mm Hg/mL; P = .01).

"[Change in peak oxygen consumption] was associated with group allocation and improved body composition," the study authors write.

"Exercise training and lifestyle intervention in patients with CKD produces improvements in CRF, body composition, and diastolic function."

Limitations of this study include the inability to separate the individual components of the lifestyle intervention; however, the authors write, "the various components are likely to be complementary and integral to promoting successful lifestyle change.", Additional study limitations include a lack of data regarding changes in doses of medication or in the amount of exercise performed by each participant, and use of noninvasive techniques to measure ventricular-arterial interaction.

"Our findings suggest that with the inclusion of structured exercise training and the right team support, improvements in fitness are achievable even in people with multiple health issues," lead author Erin Howden, PhD, also from Princess Alexandra Hospital and the University of Queensland, concluded in the news release. "Improvements in fitness translate not only to improved health outcomes, but result in gains that are transferable to tasks of everyday life."

Larger studies with longer follow-up are required to determine whether including this type of program as standard care may reduce CKD patients' risk of dying prematurely from heart disease, she concluded.

The Centre for Clinical Research Excellence–Vascular and Metabolic Health of the University of Queensland, as well as the Department of Nephrology at Princess Alexandra Hospital, supported this study. The study authors have disclosed no relevant financial relationships.

Clin J Am Soc Nephrol. Published online August 22, 2013. Abstract

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