Clinical Practice Guideline Exercise and Lifestyle in Chronic

Clinical Practice Guideline Exercise and Lifestyle in Chronic Kidney Disease

Final Version: Review Date:

April 2021 April 2026

Authors:

Dr Luke A Baker Research Associate, University of Leicester

Dr Daniel S March Research Associate, University of Leicester

Dr Thomas J Wilkinson Research Associate, University of Leicester

Miss Roseanne E Billany Clinical Trials Facilitator, University of Leicester

Prof Nicolette C Bishop Professor of Exercise Immunology, Loughborough University

Mrs Ellen M Castle Specialist Renal Physiotherapist, King's College Hospital

Dr Joseph Chilcot Senior Lecturer in Health Psychology, King’s College London

Dr Mark D Davies Renal Registrar and PhD Student, Betsi Cadwaladr University Health Board and Bangor
University

Dr Matthew P M Graham-Brown NIHR Academic Clinical Lecturer in Renal Medicine, University of Leicester

Dr Sharlene A Greenwood Consultant Physiotherapist in Renal and Exercise Rehabilitation, King’s College Hospital

Dr Naushad A Junglee Consultant in Acute Medicine and Nephrology, Cardiff and Vale UHB
Dr Archontissa M Kanavaki Research Associate, University of Leicester
Dr Courtney J Lightfoot Research Associate, University of Leicester
Dr Jamie H Macdonald Head of School, School of Sport, Health and Exercise Sciences, Bangor University
Dr Gabriella M K Rossetti Research Fellow, University of Reading
Prof. Alice C Smith Professor of Lifestyle Medicine, University of Leicester
Prof James O Burton (Chair) Professor of Renal Medicine and Honorary Consultant Nephrologist, University of Leicester
and Leicester Hospitals NHS Trust
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Endorsements
The National Institute for Health and Care Excellence (NICE) has accredited the process used by the Renal Association to produce its Clinical Practice Guidelines. Accreditation is valid for 5 years from January 2017. More information on accreditation can be viewed at www.nice.org.uk/accreditation Method used to arrive at a recommendation The recommendations for the first draft of this guideline resulted from a collective decision reached by informal discussion by the authors and, whenever necessary, with input from the Chair of the Clinical Practice Guidelines Committee. If no agreement had been reached on the appropriate grading of a recommendation, a vote would have been held and the majority opinion carried. However, this was not necessary for this guideline. Conflicts of interest statement All authors made declarations of interest in line with the policy in the Renal Association Clinical Practice Guidelines Development Manual. Further details can be obtained on request from the Renal Association.
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Contents
Introduction ............................................................................................................................................5 Summary of recommendations ..............................................................................................................8 Non-dialysis CKD (stages 1-5)................................................................................................................12
Introduction ......................................................................................................................................12 Physical activity and exercise............................................................................................................12 Weight management ........................................................................................................................19 Other lifestyle considerations (smoking, alcohol intake, drug use)..................................................21 References (Non-dialysis CKD)..........................................................................................................22 Haemodialysis .......................................................................................................................................28 Introduction ......................................................................................................................................28 Physical activity and exercise............................................................................................................28 Weight management ........................................................................................................................34 Other lifestyle considerations (smoking, alcohol intake, drug use)..................................................37 References (Haemodialysis)..............................................................................................................39 Transplantation ..................................................................................................................................... 45 Introduction ......................................................................................................................................45 Physical activity and exercise............................................................................................................46 Prehabilitation for Transplantation ..................................................................................................51 Immediate post-transplantation period ...........................................................................................51 Safety and contraindications ............................................................................................................51 Weight management ........................................................................................................................53 Other lifestyle considerations (smoking, alcohol intake, drug use)..................................................56 References (Transplantation) ...........................................................................................................57 Appendices – Non-dialysis CKD (stages 1-5).........................................................................................62 Appendices - Haemodialysis .................................................................................................................68 Appendices - Transplantation ...............................................................................................................73
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Introduction
The statement that ‘if exercise were a pill it would be one of the most widely prescribed and costeffective drugs ever invented’ has been used many times, with many slightly different iterations and with good reason; because the evidence is compelling, and the message is clear that being active provides a foundation for a longer, healthier and happier life.
Although other national and international kidney disease guideline documents include some basic recommendations for physical activity and lifestyle, at the time of publication this is the first document of its kind to set out the evidence for those people living with kidney disease, including those on haemodialysis and with a kidney transplant.
The scope of these guidelines was agreed by a multi-professional group of healthcare experts, experienced in this field, over three separate meetings of the UK Kidney Research Consortium Clinical Study Group for Exercise and Lifestyle. The authors and guideline development group entirely accept that physical activity recommendations comprise the majority of this document; this is intentional to avoid duplicating expert evidence that can be found elsewhere. Throughout, these national and international resources have been signposted, where appropriate.
Systematic literature searches were undertaken to identify all published clinical evidence relevant to the review questions and the exact parameters are outlined below. As well as pragmatic audit measures, we have included ‘Points for implementation’ which we hope will help to translate some of the recommendations into clinical practice in your units.
The group would like to particularly highlight the contributions of Drs Baker, March and Wilkinson who led the evidence reviews for the CKD, haemodialysis and transplantation sections, respectively.
Non-dialysis CKD section
Objective To perform a search for randomized control clinical trials (RCTs), systematic reviews and metaanalyses that will subsequently inform the writing of the new Renal Association Guidelines for physical activity and lifestyle in the CKD stages 1-5 (non-dialysis) population.
Study eligibility and criteria Publications were considered for inclusion if they were RCTs that involved allocation of participants at an individual or cluster level, or via quasi-randomised method. Systematic reviews alone or systematic reviews with meta-analysis of these trials were also considered for inclusion. Within these criteria, publications were subsequently screened for their target population in order to only include studies which studied the non-dialysis CKD population (stages 1-5) of adult years (>18 years).
In order to identify those studies related to the guideline topic, studies which researched physical activity, exercise, lifestyle, weight loss or smoking cessation which aimed to discuss or improve outcomes (clinical or patient reported) in non-dialysis CKD patients (stages 1-5) were included. For this purpose, the following definitions were employed:
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 Physical activity - habitual activity which includes bodily movement produced regularly by the contraction of skeletal muscles that result in a substantial increase over resting energy expenditure as part of activities of daily living.
 Exercise – activity, which was planned, structured, and repetitive bodily movement.
In topic areas in which there is currently insufficient RCTs available, epidemiological studies were included in the synthesis of studies. Utilising the expertise of the reviewing team, a pragmatic search of current guidelines available was also conducted.
Data collection and extraction Searches of systematic review databases was conducted, Cochrane and PROSPERO. MEDLINE was searched which includes the National Centre for Biotechnology Information (NCBI) PubMed. One author independently reviewed the title of every record retrieved from the electronic search. If the information given in the title suggested that the study might fit the inclusion criteria of the systematic review, the abstract was read. If the title and abstract suggested that the study might fit the inclusion criteria of the systematic review, the full article was retrieved for further assessment. Studies that did not fulfil the selection criteria of the systematic review were eliminated. The section leads then reviewed the retrieved studies to confirm whether they met the inclusion criteria. The list of search terms can be found for each of the search areas within the wider topic area in Appendix ND-CKD1. Corresponding flow citation charts of the search process can be found in Appendix NDCKD2.
Following searches, quantitative data from each review was independently extracted by the one author, which was then reviewed and approved by the section leads with variations resolved by consensus, referring back to the original data. Data was subsequently synthesized narratively in guideline format, with statements regarding the evidence being made and graded using the modified GRADE system.1
Haemodialysis section A systematic review of recent systematic reviews, meta-analyses and randomised controlled trial data pertaining to physical activity and exercise studies for individuals with end-stage kidney disease (ESKD) receiving haemodialysis was conducted to provide an up-to-date evidence base. The methodology and search strategy can be found in Appendix HD1 and HD2.
Transplantation section We first reviewed and summarised current evidence that has investigated epidemiological evidence on either physical activity and exercise levels in Kidney Transplant Recipients (KTRs) and/or the association between physical activity and exercise levels with outcomes. A systematic search of existing systematic and narrative reviews of physical activity and exercise in KTRs was conducted. NCBI MEDLINE (1966-present day) was searched using the following MESH search terms: kidney transplantation; transplant recipients; exercise; exercise therapy. An example of a full search strategy can be found in Appendix TX1. To gather the most recent evidence available, only reviews published in the last 5 years were sought (2015 to 2020). After full-text review, a total of 14 reviews relating to physical and activity in renal transplant recipients were identified. These reviews were hand-searched, and the authors sought each review for appropriate information, references of studies, and data pertaining to physical activity and exercise levels in KTRs, and the association with outcomes.
Secondly, we conducted, where appropriate, a pragmatic hand-search of all current guidelines and position statements pertinent to lifestyle, physical activity, and exercise levels in KTRs. Finally, we
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conducted a systematic search and meta-analysis of randomized clinical trials studying the effect of received a physical activity or exercise intervention, either supervised or unsupervised, on outcomes in patients with (or awaiting) a kidney transplant. The following electronic databases were searched from their date of establishment to January 2020: National Centre for Biotechnology Information (NCBI) PubMed (which includes the Medical Literature Analysis and Retrieval System Online (MEDLINE)), and the Cochrane Central Register of Controlled Trials (CENTRAL) (includes Excerpta Medica database (EMBASE), and the WHO International Clinical Trials Registry Platform (ICTRP)). The following MESH search terms were used to search all databases: kidney transplantation; transplant recipients; exercise; exercise therapy; randomised controlled trial. Full search strategies can be found in Appendix TX2. A flow of information through the different phases of the search can be found in the figure in Appendix TX3. Complete tables (Appendix TX4), forest plots (Appendix TX5), risk of bias summary (Appendix TX6), Leave-one-out’ sensitivity analysis (Appendix TX7), and funnel plots (Appendix TX8) relevant to this meta-analysis can be found in the appendices. The strengths of the recommendations and the level of supporting evidence are coded as previously using the Modified GRADE system.
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Summary of recommendations
Non-dialysis CKD (stages 1-5)
Physical activity and exercise
1.1 We recommend physical activity should be encouraged in the non-dialysis CKD population without contraindications and with stable, controlled comorbidities (1B).
1.2 We recommend non-dialysis CKD patients follow the UK Chief Medical Officers' Physical Activity Guidelines (2019), slightly adapted for this population (1B):
• Non-dialysis CKD patients should participate in daily physical activity. Some physical activity is better than none.
• Non-dialysis CKD patients should maintain or improve their physical function by undertaking activities aimed at improving or maintaining muscle strength, balance and flexibility on at least two days a week.
• Non-dialysis CKD patients should aim to accumulate 150 minutes of moderate intensity aerobic activity per week, building up gradually from current levels. Those who are already regularly active can achieve these benefits through 75 minutes of vigorous intensity activity per week, or a combination of moderate and vigorous activity.
• Non-dialysis CKD patients should break up prolonged periods of being sedentary with light activity when physically possible, or at least with standing.
1.3 We recommend that increasing physical activity or exercise levels in non-dialysis CKD patients will contribute to the following:
• Improvements in blood pressure (1B). • Improvements in physical function and capacity (1B). • Improvements in functional limitations (1C). • Improvements in health-related quality of life (1C).
1.4 We suggest that exercise may improve mental well-being, e.g. symptoms of depression and anxiety (2C).
1.5 We recommend that a prescribed combination of aerobic and muscle strengthening should be utilised to improve muscle function (1C).
Weight management
1.6 We recommend that anthropometrics should be measured and monitored (self-monitored if necessary) at regular intervals in individuals with non-dialysis CKD (1B).
1.7 We recommend that multi-professional weight management services should be available to all non-dialysis CKD patients, with referral made to tier 3 services (in-line with regional referral pathways) where appropriate (e.g. when notable changes to anthropometrics are observed) (2D).
Other lifestyle considerations (smoking, alcohol intake, drug use)
1.8 We recommend that individuals diagnosed with non-dialysis CKD (stages 1-4) stop smoking (1A).
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1.9 We recommend alcohol consumption should be within national guidelines (1B).
1.10 We recommend that individuals avoid all recreational drug use (1B).
Haemodialysis
Physical activity and exercise
2.1 We recommend that physical activity and exercise should be encouraged in the haemodialysis population where there are no contraindications (1C)
2.2 We recommend that haemodialysis patients should aim for 150 minutes of moderate intensity activity a week (or 75 minutes of vigorous activity) or a mixture of both as per the UK Chief Medical Officers’ Guideline. This may include a combination of exercise outside of dialysis (interdialytic) or exercise during dialysis (intradialytic) (1B).
• We suggest that sufficient physical activity may reduce risk of cardiovascular related and all-cause mortality in the haemodialysis population (1C).
• We suggest that increased physical activity or exercise may have favourable effects on blood pressure (2C).
2.3 Exercise during haemodialysis (intradialytic exercise) is safe with no contraindications; we therefore recommend that it should be available in all units:
• To improve cardiovascular health and physical function (1B). • To improve muscular strength (2C). • Reduce hospitalisations (2C) • To improve blood pressure control (2C). • To improve lipid profiles (2D) • To improve dialysis efficiency (2D).
2.4 We suggest that programmes for increasing physical activity and exercise are supervised and led by individuals qualified to deliver exercise and/or rehabilitation programmes in populations with chronic disease (2D).
2.5 We recommend that individual participant and staff barriers need to be addressed to optimise programme participation and adherence (1C).
Weight management
2.6 We recommend that regular anthropometric measurements should be taken to assess changes in body composition [1B]
2.7 We recommend that all individuals receiving haemodialysis maintain a BMI of between 2030 kg/m2 (1C).
2.8 We recommend that a multi professional approach should be taken to weight management. This should include the evaluation of nutritional needs along with comorbid conditions, and the promotion of physical activity and exercise supported by behaviour change techniques (2C).
2.9 We suggest that bariatric surgery is safe and may be considered for those individuals wishing to receive a transplant for whom current BMI prevents this (2C).
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Other lifestyle considerations (smoking, alcohol intake, drug use)
2.10 We recommend that individuals receiving haemodialysis stop smoking (1A).
2.11 We recommend alcohol consumption should be within national guidelines (1B).
2.12 We recommend that individuals receiving haemodialysis avoid all recreational drug use (1B).
Transplantation
Physical activity and exercise
3.1 We recommend that general physical activity should be encouraged in KTRs without contraindications [1B]
3.2 We suggest sufficient physical activity, pre- and post-transplant, can reduce all-cause and cardiovascular mortality [2C]
3.3 We recommend KTRs aim for 150 minutes of moderate to vigorous physical activity a week (or 75 minutes vigorous physical activity) as per the UK Chief Medical Officers’ Guideline [1C]
3.4 We suggest individual barriers and activators to physical activity need to be identified and addressed to optimise programme uptake and adherence [2C]
3.5 We recommend that structured exercise be considered as a method of enhancing cardiorespiratory fitness [1B]
3.6 We recommend that structured exercise be considered as a method of enhancing muscular strength and physical function [1C]
3.7 We suggest that structured exercise be considered as a method of improving health-related quality of life and increasing HDL levels [2C]
3.8 Structured exercise alone is not sufficient to attenuate increases in body mass following transplantation; we therefore suggest a multi-professional approach to appropriate weightmanagement strategies [2B]
3.9 We suggest that structured exercise should be performed at least 3x/week in KTRs without contraindications [1C]
3.10 We suggest that KTRs without contraindications undertake both aerobic and resistance exercise to maximise the effects on exercise capacity and muscle function [1B]
3.11 We suggest that a structured exercise routine be devised (and supervised if possible) by appropriately trained staff [2B]
3.12 We suggest exercise programmes should be individualised based on underlying patient goals/expectations, pathophysiology, level of experience, and graft status [2C]
Prehabilitation for transplantation
3.13 We suggest that exercise interventions prior to surgery (prehabilitation) may help increase pre-transplant physical activity levels and aid recovery post-transplant [2C]
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