REVIEW

CURRENT
OPINION Advances in exercise therapy in predialysis chronic
kidney disease, hemodialysis, peritoneal dialysis,
and kidney transplantation
Thomas J. Wilkinson a, Mara McAdams-DeMarco b,c, Paul N. Bennett d,e,
Kenneth Wilund f, on behalf of the Global Renal Exercise Network

Purpose of review
Chronic kidney disease (CKD) is characterized by poor levels of physical activity which contribute to
increased morbidity across the disease trajectory. The short nature, small samples, and poor methodology
across most studies have failed to translate the role of exercise in CKD into its adoption as a frontline
adjunct therapeutic option. This review focuses on recent advances surrounding the benefits of exercise
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interventions across the CKD spectrum.

Recent findings
Key recent advances in exercise studies have focused on the efficacy of novel intervention strategies across
the CKD spectrum. These include high-intensity interval training, virtual reality gaming, intradialytic yoga,
electrical stimulation of muscles, blood flow restriction training, and protocols combining exercise with
nutritional supplementation. Research is also beginning to explore the role of prehabilitation for patients
prior to dialysis and kidney transplantation.
Summary
Studies continue to demonstrate wide-ranging benefits of exercise across CKD; however, implementation of
exercise remains scarce. Future research needs include evaluating the efficacy of larger and/or more
comprehensive interventions on clinically important outcomes. It is hoped with increasing global evidence,
high-quality clinical studies, and sustained clinician and patient engagement, exercise programs will
become better prioritized in the nephrology field.
Keywords
chronic kidney disease, dialysis, exercise, intradialytic exercise, physical activity, physical function

INTRODUCTION programs. Furthermore, despite many nephrologists

Individuals with chronic kidney disease (CKD) are considering exercise and physical activity counsel-
characterized by poor levels of physical activity and ing as within their scope of practice and beneficial,
exercise behaviors [1]. Low levels of physical activity due to competing priorities, they do not regularly
adversely impact quality of life (QoL), functional
status, and are strongly related with mortality and a
Leicester Kidney Lifestyle Team, Department of Health Sciences, Uni-
morbidity across the disease trajectory [2,3]. For versity of Leicester, Leicester, UK, bDepartment of Surgery, Johns
decades, exercise interventions in CKD have been Hopkins University School of Medicine, cDepartment of Epidemiology,
shown to have favorable effects on patient health Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland,
d
and QoL. However, owing to the consistent short Medical Clinical Affairs, Satellite Healthcare Inc., San Jose, California,
USA, eFaculty of Health, Deakin University, Melbourne, Victoria, Australia
nature, relatively small samples, and poor method-
and fDepartment of Kinesiology and Community Health, University of
ological quality, these studies have failed to trans- Illinois at Urbana-Champaign, Champaign, Illinois, USA
late to the adoption of exercise in routine practice Correspondence to Kenneth Wilund, Department of Kinesiology and
[4]. The lack of clinical exercise programs is often Community Health, University of Illinois at Urbana-Champaign, Cham-
attributed to a lack of robust research evidence [5] paign, Illinois, USA. Tel: +1 217 265 6755; fax: +1 217 244 7322;
resulting in the low priority of physical activity and e-mail: kwilund@illinois.edu
exercise in the nephrology field [6,7], especially in Curr Opin Nephrol Hypertens 2020, 29:471–479
comparison with established cardiac or respiratory DOI:10.1097/MNH.0000000000000627

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Pharmacology and therapeutics

Significantly, in addition to aerobic exercise,

KEY POINTS strength training was not superior to balance train-
 Published studies demonstrate benefits of exercise ing, and changes occurred without notable changes
across the spectrum of CKD; however, implementation in muscle mass [11]. This suggests sufficient stimu-
of exercise programs remains scarce. lus from any form of exercise may elicit beneficial
improvements in physical performance and reduc-
 Recent studies have focused on examining the efficacy
tions in fat mass.
of novel intervention strategies across the spectrum of
CKD, including higher intensity training in CKD and A key characteristic of CKD, and thus a modifi-
renal failure, and prehabilitation for patients before able target of exercise, is reduced cardiorespiratory
kidney transplantation. fitness. However, mechanisms that contribute to
this are not clearly defined but may involve reduc-
 Future research needs include evaluating the efficacy
tions in mitochondrial function, mass, and biogen-
of larger, more global, and/or more comprehensive
interventions on clinically important outcomes. esis. In a study of n ¼ 16 individuals, Watson et al.
&
[12 ] found that CKD patients exhibit reduced
skeletal muscle mitochondrial mass and gene
expression of transcription factors involved in mito-
counsel patients [8]. As a result, the use of exercise as chondrial biogenesis compared with a non-CKD
a frontline adjunct therapeutic option in CKD control group. Significantly, these reductions were
remains unlikely for now, and physical inactivity not restored following 12 weeks of combined aero-
and poor functional status stands to remain a detri- bic and resistance exercise training, implying that
mental feature of the disease. some patients may exhibit a form of ‘exercise resis-
The current review will focus on the recent tance’ that blunts improvements in cardiorespira-
advances in evidence surrounding the benefits of tory fitness, and may explain the variable changes in
exercise interventions to patients across the CKD VO2peak sometimes observed in CKD exercise trials.
spectrum: nondialysis dependent CKD, hemodialy- Endothelial dysfunction and arterial stiffness are
sis, peritoneal dialysis, and kidney transplant recip- nontraditional risk factors of CKD-related cardiovas-
ients (KTRs). cular disease that could be targeted with exercise.
A study from the USA in 36 patients showed that
12-week moderate to vigorous aerobic exercise 3/
NONDIALYSIS DEPENDENT CHRONIC week improved microvascular function and main-
KIDNEY DISEASE tained conduit artery function, although no
Exercise-based rehabilitation programs in individu- changes were observed in central arterial hemody-
als with CKD not requiring dialysis are not yet &&
namics and arterial stiffness [13 ]. With trial out-
standard treatment. However, given these patients comes often focusing on physiological parameters,
often have reduced disease burden and increased there remains limited evidence on the effect on self-
functional capacity compared with those with later reported symptom burden. A trial conducted in
disease stages, there is a great opportunity for appro- n ¼ 36 UK CKD patients found that 12 weeks com-
priate and timely exercise-based interventions. bined aerobic and resistance exercise resulted in a
Given the popularity over the last decade in high- 14% reduction in symptom number, substantial
intensity interval training (HIIT), it is perhaps improvements in fatigue, and reductions in primar-
unsurprising that studies employing this form of ily muscle-focused symptoms such as stiffness and
novel training are now appearing in clinical trials. weakness [14].
&&
Beetham et al. [9 ] found that while 12 weeks of An important absence in many exercise inter-
HIIT (4  4 min at 80–95% peak heart rate) provided ventions is the association and study of long-term
a feasible and safe option for n ¼ 14 patients with follow-up on clinical outcomes. An increasing num-
CKD stages 3–4, no additional benefits of HIIT were ber of recent studies have shown positive effects of
observed when compared with typical moderate- exercise on different hard and surrogate outcomes.
intensity continuous training for cardiorespiratory &&
Greenwood et al. [15 ] showed that in a cohort of
fitness and markers of skeletal muscle metabolism. n ¼ 757 patients (including predialysis patients),
As such, in some patients, HIIT may be a suitable completion of a 12-week renal rehabilitation pro-
alternative to conventional exercise prescription. gram was associated with increased survival, with a
Findings from the RENEXC study conducted in ‘dose–response’ effect seen; ‘improvers’ (defined as
Sweden, which involved n ¼ 151 patients exercising an increase of 50 m in the incremental shuttle walk)
5 days per week for 12 months, found that both the had a 40% independent lower risk of a combined
strength and balance groups increased their aerobic event (e.g., death, hospitalization). While these data
capacity, strength, and physical function [10]. come from a nonrandomized study, it does provide

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 Exercise therapy in kidney disease Wilkinson et al.

support of a rehabilitation model in CKD. In a meta- intensity of exercise, and this may be contributing
analysis of 11 randomized controlled trials (RCTs) to the modest benefits that are often seen [26]. As
and n ¼ 362 patients CKD stages 3–4, Vanden stated previously, while seen in nondialysis groups
&& &&
Wyngaert et al. [16] showed favorable effects (e.g., [9 ,18 ]), BFR and HIIT are examples of train-
on estimated glomerular filtration rate (eGFR) ing protocols that can be used to increase exercise
(þ2.16 ml/min/1.73 m2) and exercise tolerance intensity but had not previously been evaluated in
(VO2peak) (þ2.39 ml/kg/min) following an 8-month hemodialysis patients. Nilsson et al. [27] recently
aerobic training program when compared with demonstrated the feasibility of a HIIT intradialytic
standard care. cycling protocol as an alternative to traditional
Exercise is increasingly being advocated for moderate-intensity intradialytic cycle training. Sim-
patients preparing for dialysis transition. In particu- ilarly, both Clarkson et al. [28] and Cardoso et al. [29]
lar, to increase cephalic vein diameter that may have demonstrated that BFR during intradialytic
optimize arteriovenous fistula maturity. An RCT cycling appears safe and tolerable. Data in healthy
showed that 8 weeks of handgrip exercises (e.g., populations indicate that BFR training may improve
squeeze ball) may increase cephalic vein diameter muscle mass and strength at lower exercise intensi-
in n ¼ 34 patients with stages 3 and 4 [17]. This effect ties than is normally required for these adaptations,
was also exhibited by Barbosa et al. [18 ] in n ¼ 26
&&
so is an intriguing exercise modality in decondi-
patients undergoing training while utilizing blood tioned individuals. While more research is needed,
flow restriction (BFR) (artery occlusion at 50% max- these studies provide examples of novel approaches
imum SBP). Although BFR did not offer any superi- that could be considered to improve physical
ority than exercise and nonocclusion. functioning in hemodialysis patients willing to
consider them.
Another approach that can be used to improve
HEMODIALYSIS the effectiveness of exercise is to include it as a
Numerous studies have been published describing component of a multifactorial intervention strat-
the benefits of exercise in hemodialysis patients egy. Several recent studies provided examples of this
[19–21], yet implementation of exercise programs by combining exercise interventions with concomi-
&&
in hemodialysis clinics is low and patient adherence tant nutritional support [30 ,31]. On the contrary,
is poor. To address these issues, some recent studies both studies failed to demonstrate that exercise
have implemented novel interventions that aim to (either intradialytic cycling or resistance training)
improve exercise adherence and/or provide more enhanced the benefits or oral nutritional supple-
robust evidence of clinical benefits of exercise in mentation on physical function and related out-
hemodialysis. Examples of some of these novel comes. These findings highlight the fact that
intervention strategies include virtual reality gam- improving hemodialysis patients’ physical function
ing, intradialytic yoga, electrical stimulation of is a significant challenge, and that novel and more
muscles, BFR training, HIIT, and protocols combin- comprehensive intervention strategies need to be
ing exercise with nutritional supplementation. Vir- evaluated.
tual reality gaming as an adjunct to an intradialytic Several recent studies have improved our under-
exercise (IDE) program proved to be feasible in two standing of the cardiovascular benefits of IDE. While
&
separate studies [22 ,23] and Birdee et al. [24] there are few reports of adverse events from exercise
recently demonstrated the feasibility of a novel in hemodialysis patients, there are theoretical con-
intradialytic yoga program. In addition, Suzuki cerns that IDE may exacerbate hemodynamic insta-
et al. [25] demonstrated improvements in muscle bility (e.g., intradialytic hypotension), especially if
strength and physical function using intradialytic performed in the later stages (3rd or 4th hour) of
electrical stimulation of leg muscles, suggesting this dialysis [32,33]. However, a recent study by Jeong
&&
may be an adjunct to physical exercise, especially for et al. [34 ] found no difference in the hemodynamic
highly deconditioned patients. Though more work effects of exercise performed during the 1st or 3rd
is needed to determine the efficacy of these inter- hour of dialysis, suggesting that exercise at any time
ventions, they are good examples of novel strategies during treatment is safe. Moreover, two separate
&&
that can be used during to get patients more physi- studies by Penny et al. [35 ] and McGuire et al.
cally active, or at least contracting their muscles, [36] both found that IDE reduced myocardial stun-
during dialysis. ning. This important new finding improves our
Another significant concern in the exercise lit- understanding of the potential clinical benefits of
erature in hemodialysis is that most interventions IDE and should help encourage clinicians to pro-
have included an extremely low volume and/or mote exercise programs in their clinics.

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Pharmacology and therapeutics

PERITONEAL DIALYSIS TRANSPLANTATION

Not unlike the hemodialysis population, the major-
ity of people receiving peritoneal dialysis are physi- Kidney transplant candidates
cally inactive, contributing to decreased physical Prehabilitation seeks to enhance a patient’s func-
function and poor QoL [1]. Although guidelines tional capacity before surgery and improve their
recommend physical activity in peritoneal dialysis, tolerance for an upcoming physiologic stressor
dialysis professionals lack the knowledge, skill, and through intensive exercise therapy [48]. This inter-
scope of practice to expertly prescribe and coordi- vention has arisen as an appealing strategy for kid-
nate optimal and personalized exercise regimens ney transplant candidates because it optimizes a
[37]. Furthermore, peritoneal dialysis patients have patient while they wait for transplantation, rather
been discouraged from participating in exercise pro- than rehabilitate them after surgery [49]. In a recent
grams because of concerns relating to the peritoneal survey, both clinicians (97%) and patients (94%)
dialysis catheter, abdominal pressure, and infection agreed that pre kidney transplant prehabilitation
[38]. This clinical approach is in contrast to would benefit patients undergoing kidney trans-
peritoneal dialysis patient’s attitudes who believe plant and make them less frail [50]. A recently
exercise improves mood, self-care abilities, QoL, and completed pilot involving prehabilitation among
decreases muscle wasting [39,40]. Considering a n ¼ 24 adult (aged 18 and older) kidney transplant
&&
peritoneal dialysis patient’s sedentary behavior candidates [51 ], suggests that physical activity
and added glucose load [41], physical activity is vital improves by 64% after 2 months. Furthermore,
in this population. kidney transplant candidates who participated in
Recent exercise studies are scarce in peritoneal prehabilitation had a shorter kidney transplant
dialysis compared with hemodialysis [42]. The larg- length of stay (5 versus 10 days) compared with
est RCT to date (n ¼ 47), conducted in Japan, age-matched, sex-matched, and race-matched con-
reported a significant improvement in incremental trols. However, a multitransplant center RCT of
shuttle walking test following 12 weeks of combined prehabilitation is needed to confirm the efficacy
&&
resistance and aerobic exercise program [43 ]. Simi- of this intervention in preventing long-term out-
larly, a US 12-week combined aerobic and resistance comes and associated costs.
intervention improved the timed-up-and-go perfor-
mance and appetite of the exercise group compared
&&
with usual care [44 ]. A noncontrolled study in Kidney transplant recipients
Thailand, measuring the effect of a resistance exer- In contrast, there are several studies of physical
cise program using traditional resistance bands, activity and exercise training among KTRs [52].
demonstrated improvement in blood pressure Previous studies have suggested that physical activ-
&
(BP), muscle strength, and QoL [45 ]. The results ity declines in the first month post kidney trans-
of this study should be interpreted with caution due plant due to surgical recovery but then increases
to the lack of a control group; however, larger stud- throughout the first year and plateaus by 5 years
ies are expected from Thailand given their high [53,54]. Recent data using actigraphy to measure
prevalence of peritoneal dialysis. physical activity and sedentary time among KTRs
Recently, exercise programs have been proposed (n ¼ 133) who were on average 9.5 years post kidney
for peritoneal dialysis patients to improve physical transplant found that on average recipients spend
function [38] and to counteract the increased glu- 9.4 h sedentary time and 20.7 min in moderate/vig-
cose load [41]. A US exercise physiologist coordi- orous physical activity per day [55]. Given these
nated program has been described consisting of findings, it is not surprising that sarcopenia, mea-
upper body, lower body, core and aerobic exercises, sured by handgrip strength and bioelectrical imped-
with exercises categorized for low, medium and high ance, is common among KTRs and associated with
physically functioning peritoneal dialysis patients mortality and hospitalization as well as poor QoL
[38]. A novel approach using aerobic cycling and [56].
walking has been proposed to counteract the caloric The previously published RCT of exercise inter-
load associated with glucose absorption [41]. Similar ventions among KTRs had different prescribed exer-
to hemodialysis exercise programs, it is likely that a cise interventions, duration of the interventions,
combined resistance and aerobic design that fits and sample sizes [52]. A recent meta-analysis of 11
into peritoneal dialysis patient’s lifestyle [46] would RCTs found that structured exercise improves small
have the greatest success in preventing the perito- arterial stiffness, VO2peak, and QoL among KTRs;
neal dialysis patients decreased physical function however, exercise did not improve BP, lipid profile,
and QoL [47]. blood glucose, kidney function, or bodyweight/BMI

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 Table 1. Summary of key recent studies of interest and their main findings
Reference Population Study design Key outcomes Main findings

Nondialysis dependent CKD

&&
Beetham et al. [9 ], n ¼ 14 CKD RCT. 12 Weeks of HIIT or Feasibility and safety; exercise capacity No adverse outcomes; "exercise
Australia (stages 3–4) moderate exercise (VO2peak); body composition; capacity; "protein synthesis; $body
muscle protein synthesis composition. No difference between
HIIT and moderate groups
&&
Kirkman et al. [13 ], USA n ¼ 36 CKD RCT. 12 Weeks of supervised Exercise capacity (VO2peak); "Exercise capacity; "microvascular
(stages 3–5) aerobic exercise training or microvascular function; conduit artery function; $conduit artery endothelial
control endothelial function; hemodynamics function; $hemodynamics and
and arterial stiffness; oxidative stress arterial stiffness; $oxidative stress
&&
Greenwood et al. [15 ], n ¼ 757 CKD Retrospective 12-year Time to combined event including Patients who did not complete the
United Kingdom (all stages) longitudinal analysis of a death, cerebrovascular accident, program had a 1.6-fold greater risk
in-centre 12-week renal myocardial infarction, and of a combined event. Dose–response
rehabilitation program hospitalization for heart failure was seen with those ‘improving’ more
showing lower risk
&&
Barbosa et al. [18 ], Brazil n ¼ 26 CKD RCT. 8 Weeks of exercise with Cephalic vein diameter; cephalic vein "Diameter of cephalic vein (control
(stages 4–5) restriction BFR or control (no distensibility; radial artery diameter; group only); "diameter of radial
BFR) systolic flow peak and mean velocity artery (BFR group only); "handgrip
in the upper limbs; forearm strength (control group only)
circumference; handgrip strength
HD
&
Segura-Orti et al. [22 ], Spain n ¼ 36 HD RCT. 20-Week Physical function tests, including normal "Physical function and exercise
strength þ aerobic training gait speed, STS 60, OLHR, and adherence were similar between
(Ex) OR 16 weeks of aerobic 6MWT; and exercise adherence groups. This suggests intradialytic VR

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and strength training þ 4 is feasible and reasonable alternative
weeks VR gaming to traditional intradialytic exercise
programs
&&
Jeong et al. [30 ], USA n ¼ 138 HD RCT. 3 Groups, 12-month ISWT; muscle strength; gait speed; $ISWT or most secondary outcomes.
intervention: control; OPS (30- cardiovascular function (PWV, Trends for "gait speed and diastolic
g whey); OPS þ intradialytic systolic and diastolic function) function in OPS þ exercise group only
cycling
&&
Jeong et al. [34 ], USA n ¼ 12 HD Cross-over design. 3 Treatments: Intradialytic hemodynamic variables, During 1st and 3rd hour exercise, there
control day; IDE cycling in 1st including blood pressure, autonomic were transient "blood pressure and
hour (30 min); IDE in 3rd hour function, cardiac output, stroke cardiac output, but $in variables at
(30 min) volume, and TPR end of dialysis with or without ICE
&&
Penny et al. [35 ], n ¼ 19 HD Cross-over design; 2 days: Myocardial stunning (regional wall At peak HD stress, the number of
Canada control; IDE cycling (30 min) motion abnormalities; RWMA) at 3 stunned cardiac segments was#
time points during dialysis
(preexercise, postexercise, and peak
stress) (15 min before the end of
dialysis)

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PD
Uchiyama et al. n ¼ 47 PD (n ¼ 13 RCT. 12 Weeks of a combined Exercise capacity (ISWT); HRQoL; "Exercise capacity; $handgrip
&&
[43 ], Japan APD, n ¼ 34 CAPD) resistance and aerobic anthropometry; biochemistry; baPWV strength; $quadriceps; "HRQoL;

www.co-nephrolhypertens.com
exercise program $anthropometry; "albumin;
$baPWV
Exercise therapy in kidney disease Wilkinson et al.

475
 476
Table 1 (Continued)
Reference Population Study design Key outcomes Main findings

Bennett et al. n ¼ 26 APD RCT. 12 Weeks of a combined Feasibility and safety; physical function; 63% Recruitment; 72% retention; 77%
&&
[44 ], USA resistance and aerobic PROMs sustained exercise following study;
exercise program "TUG; "appetite
Aramrussameekul and n ¼ 20 CAPD Pre–post. 12-Week home-based BP; hand, leg, back strength; HRQoL #SBP and DBP; "hand, leg, back
Changsirikunchai rubber rope exercise strength; "HRQoL
&
[45 ], Thailand
Transplantation
McAdams-DeMarco n ¼ 24 KT candidates active on Non-RCT. Average of 28 weekly Feasibility; physical activity; length of "Physical activity; #length of stay. High
&&
et al. [51 ], USA the waitlist within 3–6 months prehabilitation sessions (1-h stay; patient feedback level of satisfaction with the
Pharmacology and therapeutics

of transplantation supervised physical therapy) prehabilitation intervention. No

(matched KT control group) adverse events
Roi et al. [58], Italy n ¼ 99 KT recipients at least RCT. 12-Month 3 times/week Renal function; lipid values; blood "Exercise capacity; "muscular strength;
6 months after KT supervised aerobic and chemistry; exercise capacity "power; #BMI; "HRQoL (physical

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resistance training (VO2peak); muscle strength (plantar function, physical-role limitations, and
flexor) and power (countermovement social functioning scales)
jump height); BMI; HRQoL
Serper et al. [59], USA n ¼ 61 KT recipients and n ¼ 66 RCT. 12 Weeks. 3 Arms: arm 1: Change in patient weight (after 4 $Weight change; those in either
liver transplant recipients (9- standard of care and months); proportion of days at the intervention arm was more likely to
month posttransplantation) wearable physical activity target of 7000 steps per day achieve >7000 steps compared with
trackers, access to an online controls
portal; arm 2: arm 1 and step
goals and health engagement
questions with financial
incentives. Enrolled in a
physical activity program with
individualized goals; control
group
&
Henggeler et al. [60 ], n ¼ 37 KT recipients RCT. 12 Months. Intensive Body weight at 6-month post-KT; $Body weight; $secondary outcomes
New Zealand nutrition intervention change in body weight; between groups
(individualized nutrition and anthropometric measures; body
exercise counseling; 12 composition; resting energy
dietitian visits; 3 exercise expenditure; physical function;
physiologist visits over 12 physical activity; serum biochemistry;
months) or to standard HRQoL
nutrition care (guideline
based; 4 dietitian visits)

6MWT, 6-min walk test; APD, automated peritoneal dialysis; baPWV, brachial–ankle pulse wave velocity; BFR, blood flow restriction; BP, blood pressure; CAPD, continuous ambulatory peritoneal dialysis; CKD, chronic
kidney disease; HD, hemodialysis; HIIT, high-intensity interval training; HRQoL, health-related quality of life; IDE, intradialytic exercise; ISWT, incremental shuttle walk test; KT, kidney transplant; OPS, oral protein

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supplementation; PD, peritoneal dialysis; PROM, patient-reported outcome measure; RCT, randomized controlled trial; RWMA, regional wall motion abnormality; STS, sit-to-stand test; TUG, timed up and go test; VR,
virtual reality.

Volume 29  Number 5  September 2020

 Exercise therapy in kidney disease Wilkinson et al.

Table 2. Summary of key points/findings with areas for future research

Key findings and areas for future research

Urgent research is required to determine how we decrease physical deterioration prior to renal replacement therapy to improve RRT outcomes
In particular, the role of prehabilitation needs additional investigation in those being prepared for a KT or dialysis to elucidate is long-term
effects
Further research is needed to clarify upon the optimal dose, timing, and frequency of exercise, particularly in those requiring a KT, HD, and
PD
There is increasing use of novel interventions, such as BFR or HIIT, that aim to improve exercise adherence; however, further research is
needed to clarify whether these provide greater clinical benefits
Despite an increase in high-quality evidence, there also remains an important role of the healthcare provider in the promotion of exercise.
There is a need for the evaluation of effective and efficient counseling strategies and a role for the routine involvement of exercise specialists
in kidney care

BFR, blood flow restriction; HD, hemodialysis; HIIT, high-intensity interval training; KT, kidney transplant; PD, peritoneal dialysis; RRT, Renal Replacement Therapy.

[57]. A recent RCT of n ¼ 99 KTRs (n ¼ 85 completing CONCLUSION

the study), found that recipients who were random- There is an ever-increasing number of clinical stud-
ized to 12 months of supervised exercise training ies showing the beneficial role of exercise across the
three times/week were associated with an increased CKD spectrum (a summary of the key recent studies
maximum workload, VO2peak, strength, and and their findings are shown in Table 1). However,
decreased BMI as well as health-related QoL as com- while examples of successful programs do exist,
pared with recipients randomized to 12 months of implementation and recognition of exercise as a
general recommendations about physical activity safe and adjunct therapeutic option in nephrology
[58]. However, a 12-month intervention is a longer remain limited across the globe. A summary of the
intervention period than in many other studies. main findings from this review with areas for future
Furthermore, the LIFT study of n ¼ 61 KTRs and liver research can be found in Table 2. Beyond clinical
transplant recipients (median 9-month posttrans- studies, one key and notable advancement in the
plantation) randomized recipients to standard of field of renal exercise was the recent establishment
care or one of two intervention arms: increasing of the Global Renal Exercise Working Group, an
the number of steps by 15% using either accelerom- international collaborative group of researchers,
eter with and without financial incentives and patients, and clinicians. This group, facilitated by
health engagement questions [59]. This study found the ISRNM, has an overarching objective to increase
no differences in weight change at 3 months across the uptake of exercise and lifestyle interventions
all three arms but did find that those randomized into routine clinical care and provides a multidisci-
to either intervention arm were more likely to plinary network to help address the key global
achieve 7000 steps or more compared with standard &&
research priorities in the area [63 ]. It is hoped with
of care. increasing evidence, high-quality clinical studies,
One promising study of n ¼ 37 KTRs combined and better clinician and patient engagement, exer-
exercise with intensive nutrition but found that this cise programs will become prioritized in nephrology
intervention did not prevent weight gain in the first resulting in substantial benefits in patient health-
year after kidney transplant compared with standard care across the globe.
nutritional care [60 ]. Finally, a study of n ¼ 24 KTRs
&

and n ¼ 15 patients with CKD found that an indi-

Acknowledgements
vidualized, structured physical activity intervention
The authors acknowledge the support of the Global Renal
was associated with an improved metabolic profile,
Exercise (GREX) network in the development of this
body composition, QoL, and eGFR (only among
article.
recipients) as well as reduced inflammation
[61,62]. The review of the previous and current
Financial support and sponsorship
literature suggests that structured resistance exercise
training for 3–6 months may be beneficial in adult M.M.-D. is funded by the National Institutes of
KTRs who are healthy enough to exercise; however, Health (NIH): R01AG055781, R01DK120518, and
changes of BMI may only be observed after R01DK114074.
12 months of intervention. One challenge is identi-
fying the right time post kidney transplant for Conflicts of interest
exercise interventions. There are no conflicts of interest.

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Pharmacology and therapeutics

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