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SHORT COMMUNICATIONThe BASES expert statement on exercise therapy for people withchronic kidney diseasePELAGIA KOUFAKI1,SHARLENE GREENWOOD2,PATRICIA PAINTER3&THOMAS MERCER41School of Health Sciences,Queen Margaret University,UK,2Renal Exercise and Rehabilitation Team,Kings CollegeHospital,London,UK,3Department of Physical Therapy,University of Utah,Salt Lake City,USA and4School of HealthSciences,Queen Margaret University,Edinburgh,UK(Accepted 6 February 2015)AbstractChronickidneydisease(CKD)isbecomingaserioushealthproblemthroughouttheworldandisoneofthemostpotentknownriskfactorsforcardiovasculardisease,whichistheleadingcauseofmorbidityandmortalityinthispatientpopulation.Physicalinactivityhas emerged as a significant and independent risk factor for accelerated deterioration of kidney function,physical function,cardiovascular function and quality of life in people in all stages of CKD.CKD specific research evidence,combined with thestrong evidence on the multiple health benefits of regular and adequate amounts of PA in other cardiometabolic conditions,hasresulted in physical inactivity being identified by national and international CKD clinical practice guidelines as one of the multipleriskfactorsthatrequiresimultaneousandearlyinterventionforoptimumprevention/managementofCKD.Despitethisrealisation,physical inactivity is not systematically addressed by renal care teams.The purpose of this expert statement is therefore to informexercise and renal care specialists about the clinical value of exercise therapy in CKD,as well as to provide some practicalrecommendations on how to more effectively translate the existing evidence into effective clinical practice.Keywords:physical activity,exercise rehabilitation,haemodialysis,renal failureIntroductionChronic kidney disease(CKD)is a long-term meta-bolic condition,characterised by gradual loss of thekidneys regulatory and excretory functions.It iscategorised into 5 stages(CKD15)based on thekidneysestimatedglomerularfiltrationrate(eGFR).Stage 5(eGFR 15 ml/min/1.732)markstheintroductionofrenalreplacementtherapy(RRT),such as dialysis or transplantation,to sustainlife.The Health Survey for England(2009)estimatesthat about 46%(2.7 million)of the adult popula-tion have CKD 35(GRF 17.5 ml kg1 min1wasassociatedwithbettersurvivalratesover3.5 years in patients on haemodialysis.Gait speed1.3 m s1was associated with 1826%reducedrisk of rapid kidney function decline in CKD 24.Patient reported physical function composite score(PCS),from the SF-36 questionnaire,indicated thata one point increase corresponded to 2%reductionin mortality rate,whilst a total PCS 250 mg dl1or 100 mg dl1Patientswhoarepronetohypoglycaemiashould check capillary blood glucose before,during and after exercise and have high glycae-mic index snacks readily availablePostpone/stop exercise if patients experiencesymptoms of deep vein thrombosis such as unu-sual swelling,redness and pain in the lower legsPeople with open wounds and poorly healedsores should avoid swimming pools and weightbearing activities until sores are fully healedPatients should be shown how to avoid elicitinga Valsalva manoeuvre response particularly dur-ing strength training programmesPostpone/stop exercise if patients experience diz-ziness,severe headache,or fluctuating HR,BPresponsesConsult with a renal physician about exercisemedication interactions and review dose ifpatientswhoregularlyexerciseconsistentlyexperience hypotensive episodes and symptomsafter dialysis and exercisePhysical function assessment for patients onhaemodialysis,should ideally take place onnon-dialysis days and not after the weekend,or just prior or after haemodialysisThe arm with the fistula can be exercised aslong as the fistula is well healed and the indivi-dual is not connected to a dialysis machine.Patients on peritoneal dialysis may find it easierto exercise when the peritoneum is empty andso avoid increased pressure on the diaphragmthat may cause discomfort or leakage at thecatheter site.“Exercise on prescription”planCurrent evidence seems to suggest that there is a mini-mum volume of exercise/PA(1000 kcal week1)thatneeds to be achieved for health benefits to be realised(Start active,stay active,2011).Structured and super-vised exercise plans delivered in clinical or communitysettings can contribute towards achieving this mini-mum target volume of exercise/PA.Emphasis how-ever,should be placed on advice and support foradditional daily PA opportunities that individualsshould engage with.In any case,existing evidencedictates that an“exercise on prescription”plan shouldbe based on patients assessed physical function andmotivation with the aim toPrescribeexerciseusingtheFrequency,Intensity,Time,Type(FITT)principleFrequency:stable patients on haemodialysis cansafely follow a structured exercise programmedelivered during the first 2 h of dialysis,3 times/week.Advice for regular daily PA participationcan extend to most days of the week as percurrent PA recommendations for elderly people(Start active,stay active,2011).Intensity:moderate intensity(as per ACSM cri-teria)aerobic(orresistance)trainingpro-grammes,delivered during dialysis(aerobicexercise mainly)or on non-dialysis days in allstages of CKD,has been reported as safe andclinically effective for improving cardiovascularreserve capacity and muscular strength.Time:the individuals starting level and clinicalstatus will determine the time frame within whichthe prescribed exercise dose can be safely deliv-ered(see Table I as an example).Type:there are no reported restrictions as to whattype of exercise can be safely used in people withCKD.However,safety precautions as listed ear-lier have been highlighted in the literature.4P.Koufaki et al.Downloaded by University of California,San Diego at 23:08 26 March 2015 Encourage progression and monitor compli-ance,adherence,drawbacksGetting the exercise dose right is very importantbut difficult to quantify without systematic mea-surement of all FITT components.Closerexamination of reported group and individualresearchdatahighlightslargevariabilityinresponsivenessandadaptationstoexercisetraining that probably stems from variability inthe total exercise dose and biological variability.Therefore,for the time being emphasis shouldbe given to recommendations for sustainableand gradual progression of exercise stimulus.Re-assess physical function and PA at leastevery 46 months,readjust exercise treatmentplan and provide feedbackDocument goals,outcomes and progressPatient education and supportLink patients with local and national kidney patientassociations and community networks to make bestuse of free available resources and educational mate-rials.Provide patients with written information andactively encourage their involvement in as many safeactivities as possible.Summary of conclusions and recommendationsThe benefits of regular PA in cardiovascular diseaseand diabetes are well established and although theevidence base in CKD needs to be strengthened,existing data indicate similar benefits.We thereforesuggest that every stable patient with CKD,irrespec-tive of age,gender,comorbidities or prior exerciseexperience,should be provided with specific writtenadvice on how to safely and effectively increase PA to(i)enhance confidence and self-efficacy in perform-ing physical activities;(ii)attenuate deterioration ofphysical function and associated limitations in ADL;(iii)increasephysiologicalreserve;(iv)reducecomorbid events;and(v)enhance QoL.The challenge is to engage and educate all stake-holders in developing a renal exercise-rehabilitationservice that is safe,feasible,sustainable and resourcedto facilitate its incorporation into the integrated care ofTable I.Indicative initial 3 month exercise prescription plan for an elderly patient on haemodialysis.Primary and secondary outcomesGoalsExercise treatment plan(monitortolerance and vital signs)ProgressionAdditionalinterventioncomponents1.Severe muscle weaknessImprove lower bodystrengthF:2/weekWeek 12I:60%of peak workload achieved atassessment(if testing progressedwithout complications)2.Severe difficulty to performbasic ADLsIncrease exercisetoleranceT:CyclingT:15 min in total in 5+5+5F:3/weekWeeks 353.Low threshold exertional fatigueI:60%of peak workloadT:cyclingT:20 min(10+10 or any othercombination)F:3/weekWeeks 691020 sit-to-standtransfers at home4 days/weekI:60%of peak workloadT:cyclingT:20 minF:2/weekI:60%5RMT:resistance weightsT:10 min with rests(2 sets 8-reps dynamic leg exercises)F:3/weekWeeks 10132 20 sit-to-standtransfers 4 days/week unsupportedI:70%of peak workloadT:cyclingT:30 minF:2/weekI:70%5RMT:resistance weightsT:15 min with rests(3 sets 810reps(dynamic leg exercise)Re-assessInterpretMonitor/Adjust/ContinueFeedbackAdviseNote:ADL:Activities of daily living,FITT:Frequency,Intensity,Type,Time,RM:Repetition maximum.Exercise therapy in CKD5Downloaded by University of California,San Diego at 23:08 26 March 2015 CKD patients across the entire disease trajectory.Thiswill require the recommendation for routine monitor-ing and documentation of the physical function andactivity levels of patients,in addition to the effects ofany exercise participation,within electronic medicalrecords and in national registries.This should precipi-tate the consensus generation of core outcomes for thescreening,assessment,monitoring,as well as evalua-tion of exercise training effectiveness for people withCKD(Koufaki&Kouidi,2010).Renal rehabilitationservices should include(clinical)exercise scientistsalongside physiotherapists to support the developmentand evaluation of individualised,effective and sustain-able PA and exercise plans.The role of these indivi-dualsandtheiractivities,willbecentraltothemanagedtransition of rehabilitation services towards commu-nitybasedpre-dialysis(stages24)andpost-transplan-tation services involving,where appropriate,self-managed 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