Renal Function and Failure

• The following are study notes based on the provided images.

Renal Function

• Kidney functions include regulating extracellular fluid volume, serum osmolality, electrolyte and acid-base balance and secretion of Renin and Erythropoietin.
• Disturbed kidney function can affect almost every other system in the body.
• Chronic Renal Failure/Insufficiency (CRF, CRI) has multiple major complications, especially with the kidneys.
• CRF/CRI can lead to hypertension (HTN), pericarditis, pericardial effusion, tamponade, anemia, bleeding disorders, myopathy, and peripheral neuropathy.

Renal Failure

• End Stage Renal Disease (ESRD) includes cardiovascular complications that account for 50% of deaths, including MI, CHF, and CVA.
• Hypertension is both a cause and a consequence of renal disease.
• Treatments for renal failure include conservative management, transplant, control of diet, fluid balance, BP, and mineral metabolism.
• Dialysis replaces the excretory functions of the kidney, including Hemodialysis (HD) and Peritoneal dialysis (PD).
• In chronic kidney disease, patients tend to have low functional capacity which is about 50% compared to healthy, age and sex-matched controls.
• Research indicates exercise performed safely before, during, or after HD can benefit patients.
• Exercise can increase VO2max by 20-25% in 10 weeks to 1 year of treatment
• Exercise can improve lipid profiles, BP control, insulin sensitivity, glucose metabolism, RBC count, and muscle strength.

Exercise Considerations for Patients with Renal Failure

• When starting exercises with patients in renal failure, begin with low intensity and gradually increase based on patient tolerance.
• Rating of Perceived Exertion (RPE) should be used because heart rate (HR) may not be a reliable indicator of exercise intensity.
• Influencing factors include anemia, impaired cardiac function, deconditioning, abnormal peripheral metabolism, and systemic function during exercise.
• Leg fatigue is a common complaint for these patients.
• Precautions include monitoring vital signs, adjusting routines based on daily symptoms, and awareness of medications and side effects.
• Consider the arm with the AV fistula and possible bone issues related to calcium/phosphorus balance.
• Possible bone issues come with long-term dialysis patients relating to calcium and phosphorus imbalance.

Collagen Vascular Disease

• Collagen Vascular Disease is a diverse group of systemic diseases.
• Vascular abnormalities are diffuse and variable.
• Joint, muscle, and connective tissue lesions are inflammatory.
• Collagen vascular diseases have the highest mortality and morbidity rates and affect kidneys, heart, and brain.
• Can affect all elements of the respiratory system: muscles, pleura, airways, vessels, interstitium.
• Specific cardiopulmonary involvement is related to RA, Lupus, ankylosing spondylosis, and progressive systemic sclerosis.

Connective Tissue Diseases

• Connective tissue diseases have the potential to affect the great arteries, valves, skeletal system, and skin.
• Marfan's Syndrome is a genetic abnormality, cardiac manifestations range from minimal to severe and reflect the response of abnormal connective tissue to prolonged hemodynamic stress.
• Frequent issues with valves and aneurysms(often in the aorta) that are related to rapid growth.

Cancer

• Development of aggressive treatments has created toxicity in the heart and lungs.
• Radiation (XRT) can cause pericarditis, MI (ischemia and infarction), vascular injury, myocardial fibrosis, atherosclerosis, and pneumonitis.
• Chemotherapy can cause cardiomyopathy, later stage ventricular dysfunction, and pneumonitis.
• Both XRT & chemotherapy can affect hematopoiesis.
• Hematopoiesis depends on the area being irradiated (lots of bone marrow or not).
• Can cause anemia, thrombocytopenia, neutropenia/leukopenia.

Hematologic Disorders

• Symptoms of anemia include fatigue, headaches, and exertional dyspnea.
• Patients with a past medical history (PMH) of CAD will see symptoms of anemia easier
• Compensatory mechanisms include decreased hemoglobin-O2 affinity, increased CO, decreased peripheral resistance, decreased blood viscosity, decreased circulatory time, increased O2 extraction, and redistribution of blood flow.
• The goal is to preserve tissue oxygenation.
• Disorders can affect platelets: thrombocytopenia (including Idiopathic thrombocytopenia (ITP)) and thrombocytosis
• Disorders can affect white blood cells: leukopenia and leukocytosis.
• Considerations related to bleeding and clotting are important for platelet disorders

HIV/AIDS

• Pulmonary issues are prevalent: TB/bronchiectasis/cancer
• Cardiac issues can develop, often related to the use of HAART, which may increase the risk of cardiovascular dysfunction & CVD.
• BP may also be affected by HTN, often related to lipid abnormalities.
• Prevalence is variable.
• Can cause pericardial effusion
• Can cause LV dysfunction and dilated CM

Hot Environments: Exercise Considerations

• Heat causes peripheral vasodilation to increase blood flow to the skin and stimulates sweat glands to secrete water & electrolytes onto the skin.
• HYPERTHERMIA: occurs when the amount of metabolic heat exceeds heat loss.
• The cardiovascular system is essential for temperature regulation.
• Conditions that occur in hot environment: Exertional Heat Exhaustion, Exertional Heat Cramps, Exertional Heat stroke and Heat syncope
• Increased HR can occur in hot environments
• Dehydration decreases blood volume which may lead to ischemia
• Temperature, humidity, and direct sun exposure impact exercise in hot environments
• Intensity and/or duration may need to be lowered in hot environments.
• Loose clothing, sunscreen, shade and cooler days can help exercise in hot environments

Cold Environments: Exercise Considerations

• Cold causes vasoconstriction.
• Usually does not increase strain or injury risk.
• Conditions that occur in cold environments: Hypothermia and Frostbite
• Decreased exercise capability and performance can occur in cold environments.
• Can cause increased arterial BP.
• Higher risk for ischemia and vasospasm.
• Need to adequately hydrate despite lack of noticeable perspiration.
• Wind chill factor.
• Layer clothing, cover extremities, and warm breathing air with scarf.

High Altitude: Exercise Considerations

• Higher altitude leads to a progressive decrease in atmospheric pressure, which lowers the partial pressure of O2 in inspired air and decreases arterial oxygen levels.
• Increased ventilation and increased cardiac output are usually related to increased HR.
• Acclimation usually occurs within 1 week.
• Increased time for task completion and more frequent rest breaks are needed.
• Conditions related to higher altitude: Acute mountain sickness, high-altitude pulmonary edema, & high-altitude cerebral edema and bronchitis/severe coughing spasms.