Renal Rehabilitation Lecture PDF

# Renal Rehabilitation Dr. Badr Al-Amir Hassan Lecturer of physical therapy for cardiovascular disorders and geriatrics ## Objectives: - Identify the chronic kidney disorders (CKD) - Discuss renal rehabilitation - Identify the physical therapist role in renal rehabilitation - Relate the kidney di...

# Renal Rehabilitation Dr. Badr Al-Amir Hassan Lecturer of physical therapy for cardiovascular disorders and geriatrics ## Objectives: - Identify the chronic kidney disorders (CKD) - Discuss renal rehabilitation - Identify the physical therapist role in renal rehabilitation - Relate the kidney diseases to the appropriate intervention - Employ this knowledge in submitting a case study proposal ## Renal rehabilitation (RR) - **Renal rehabilitation (RR):** Is a coordinated, multidisciplinary intervention designed to optimize a renal patient's physical, psychological, and social functioning, thus reducing morbidity and mortality. - **Chronic kidney disease (CKD):** Is a progressive condition that adversely affects musculoskeletal health. **Renal rehabilitation (RR) includes five major components such as:** - Exercise training - Diet - Fluid management - Medication & medical surveillance - Education, psychological & vocational counselling ## Indications for Renal rehabilitation (RR) - Nephritis/nephrosis - Chronic kidney diseases eg Polycystic Kidney Disease, Diabetic kidney. Alcoholic kidney - Dialysis therapy - Kidney transplantation ## The aims of the Renal rehabilitation (RR) are : - To optimize a patient’s physical, psychological, and social functioning - To stabilize, slow, or even reverse the progression of renal deterioration - Improving exercise tolerance - Preventing the onset and worsening of heart failure - Reducing morbidity and mortality ## Renal rehabilitation (RR) teamwork - Doctors - Rehabilitation therapists - Diet nutritionists - Nursing specialists - Social workers - Pharmacists - Therapists ## Causes of decreased exercise endurance in (CKD) - **Protein-energy wasting, (PEW):** Is a condition in which body protein mass is reduced by protein catabolism - Protein-energy malnutrition - Arteriosclerosis - **Uremic acidosis, Inflammatory cachexia**, which lead to - Sarcopenia - And are aggravated by a sedentary lifestyle ## Clinical picture of CKD - **Frailty:** Is a condition in which malnutrition and wasting are observed - Osteoporosis - Skeletal muscle wasting - Cardiovascular hypertrophy - Vascular calcification - Reduced exercise endurance (VO2 max) and Deconditioning - Premature aging ## Physiotherapy Management aims are to: - Improve muscle strength, mobility and fitness - Improve quality of life - Reduce blood pressure - Improve blood sugar control - Improve your heart and lung function - Control weight and - Improve self-esteem - Counteract/reverse the side effects of steroidal treatment, such as muscle wasting, bone thinning and weight gain after transplant. ## Renal rehabilitation for patients with nephritis and nephrotic syndrome There is no clear evidence that the prognosis of glomerulonephritis nor nephrotic syndrome in remission are exacerbated by exercise or that the prognosis is improved by rest and exercise restriction. During the administration of a low dose of steroid as maintenance therapy in the remission period, appropriate exercise therapy is considered necessary from the viewpoint of prevention of obesity and steroid-induced osteoporosis. ## Renal rehabilitation for patients with non-dialysis dependent CKD Recent guidelines recommend moderate exercise and emphasize comprehensive, favorable effects of exercise therapy: - Improvements in activity of daily living (ADL) - Improvement of cardiovascular function - Improvement of muscle metabolism and - Improvement of psychosocial conditions - Improving QOL through enhanced cardiovascular fitness - Improving bone strength - Improve or maintain exercise tolerance ## Renal rehabilitation for patients on hemodialysis - **Dialysis therapy** is a treatment for end-stage renal disease. - Have a very high mortality risk due to cardiovascular diseases such as chronic heart failure. - And sedentary patients with CKD undergoing dialysis have an even higher mortality risk ## Renal rehabilitation (RR) in dialysis To prevent muscle protein catabolism, in addition to exercise, A sufficient supply of energy, including: - Carbohydrates - Protein - Iron - Vitamins is needed. Dialysis treatment decreases the digestive function and energy loss. And due to dialysis, patients are recommended to ingest 1.2-fold more protein than the regular population. ## Benefits of RR for dialysis patients: - Physical function improvement - QOL were improved by exercise, which is a major component of renal rehabilitation - Intradialytic exercise protocols had positive outcomes in chronic kidney disease patients with poor cardiopulmonary function and reduced exercise tolerance and ventilatory efficiency. - Improve or maintain the survival - Improve exercise tolerance, improvements were observed in exercise tolerance (VO2) in clinical studies with an intervention period of ≥ 6 months - Improve walking ability - Improve muscle strength - Improve muscle mass - Improve ADL. The improvement in exercise tolerance was greater in clinical studies using both aerobic exercise therapy and resistance training in combination Also, there was a report that the improvement in exercise tolerance was greater by exercise therapy under supervision on non-dialysis days compared with that during dialysis. ## Renal rehabilitation for renal transplant recipients - Renal transplant recipients are orally administered 2-3 immunosuppressants including corticosteroid as long as the kidney graft is functioning. - Renal failure and corticosteroid can be risk factors for muscle atrophy/ weakness, obesity is often concurrent with sarcopenia. - It is considered best to improve the lifestyle by dietary and exercise therapies. - The body weight gain should be controlled within about 5% of the body weight before transplantation, targeting a body mass index (BMI) of ≤ 25 kg/m2. - The exercise protocol for renal transplant recipients is considered to be similar to that for CKD patients. - Frailty/low physical activity adversely affects the vital prognosis of renal transplant recipients. ## Physiotherapy Management The physiotherapist input in the RR is to design a good comprehensive exercise program: - They are held over 6-12 weeks - with classes ranging between 1-2 hours - with participants committed to performing exercises at home on at least two other days a week. # The program should have: - A warm-up and cool down - A strengthening component - A cardiovascular component - A flexibility section The therapist also needs to monitor progression and educate clients in monitoring their progress. ## Physical activity and exercise in chronic kidney disease: consensus statements from the Physical Exercise Working Group of the Italian Society of Nephrology The document includes 16 statements about physical activity and exercise in CKD patients, illustrated with pictures. The following is a brief description of each statement: ### Statement 1: - "Physical activity" and "exercise" have distinct meanings and should be used accordingly. ### Statement 2: - Physical inactivity is prevalent in CKD patients and represents a modifiable risk factor for increased mortality and morbidity, as well as for reduced quality of life. ### Statement 3: - Physical activity and exercise significantly benefit CKD patients, particularly in improving physical function, cardiorespiratory capacity, muscle strength and overall quality of life. ### Statement 4: - Physical exercise is safe in CKD patients when appropriately performed ### Statement 5: - Physical function assessment can be performed routinely through physical performance tests and patient-focused questionnaires. ### Statement 6: - Monitoring physical activity levels using self-report instruments or objective measures is advisable to counteract sedentary behavior ### Statement 7: - Protein restriction does not blunt or prevent the favorable effects of exercise on muscle strength and mass in CKD patients ### Statement 8: - Dietary supplements combined with exercise are an effective strategy for preventing sarcopenia or protein-energy wasting in CKD patients, including those on dialysis. ### Statement 9: - Barriers to physical activity in the CKD population are well known: each nephrology and dialysis unit needs to identify its center-specific barriers and establish a detailed plan for overcoming them. ### Statement 10: - It is crucial to personalize physical activity prescriptions, which can be provided by a nephrologist, while in the presence of functional limitations, a physiotherapist or sports medicine physician consultation is generally needed. ### Statement 11: - Exercise training for CKD patients can be undertaken alone or in groups, at home, in a dialysis unit, or in a sports facility ### Statement 12: - Exercise training for CKD patients should include aerobic and resistance exercises ### Statement 13: - Exercise programs should be carried out regularly for at least 12 weeks to be effective. ### Statement 14: - Physical activity and exercise programs should begin with low intensity and progress gradually according to the patient's tolerance ### Statement 15: - In everyday clinical practice, renal rehabilitation should be provided by a healthcare team. ### Statement 16: - New technologies, such as interactive social media creation and virtual reality gaming, could improve CKD patients’ adherence to exercise implementation. ## References - Villanego F, Naranjo J, Vigara LA, Cazorla JM, Montero ME, García T, Torrado J, Mazuecos A. Impact of physical exercise in patients with chronic kidney disease: Sistematic review and meta-analysis. Nefrologia (Engl Ed). 2020 May-Jun;40(3):237-252. English, Spanish. doi: 10.1016/j.nefro.2020.01.002. Epub 2020 Apr 15. PMID: 32305232. - Nakamura K, Sasaki T, Yamamoto S, Hayashi H, Ako S, Tanaka Y. Effects of exercise on kidney and physical function in patients with non-dialysis chronic kidney disease: a systematic review and meta-analysis. Sci Rep. 2020 Oct 23;10(1):18195. doi: 10.1038/s41598-020-75405-x. PMID: 33097801; PMCID: PMC7585437. - Yamagata, K., Hoshino, J., Sugiyama, H. et al. Clinical practice guideline for renal rehabilitation: systematic reviews and recommendations of exercise therapies in patients with kidney diseases. Ren Replace Ther 5, 28 (2019).https://doi.org/10.1186/s41100-019-0209-8 - Battaglia Y, Baciga F, Bulighin F, Amicone M, Mosconi G, Storari A, Brugnano R, Pozzato M, Motta D, D'alessandro C, Torino C, Mallamaci F, Cupisti A, Aucella F, Capitanini A; Working Group of Physical Exercise of Italian Society of Nephrology. Physical activity and exercise in chronic kidney disease: consensus statements from the Physical Exercise Working Group of the Italian Society of Nephrology. J Nephrol. 2024 Sep 13. doi: 10.1007/s40620-024-02049-9. Epub ahead of print. PMID: 39269600. - https://www.physio-pedia.com/Renal_Rehabilitation - Hoshino J. Renal Rehabilitation: Exercise Intervention and Nutritional Support in Dialysis Patients. Nutrients. 2021 Apr 24;13(5):1444. doi: 10.3390/nu 13051444. PMID: 33923264; PMCID: PMC8145577. - Kohzuki M. Renal Rehabilitation: Present and Future Perspectives. J Clin Med. 2024 Jan 18;13(2):552. doi: 10.3390/jcm 13020552. PMID: 38256684; PMCID: PMC10816861.