The role of exercise training on cardiovascular risk factors and heart disease in patients with chronic kidney disease G3-G5 and G5D: A Clinical Consensus Statement of the European Association of Preventive Cardiology (EAPC) of the ESC and the European Association of Rehabilitation in Chronic Kidney Disease (EURORECKD).

Cardiovascular (CV) morbidity and mortality is high in patients with chronic kidney disease (CKD). Most patients reveal a high prevalence of CV risk factors such as diabetes or arterial hypertension and many have manifest cardiovascular disease (CVD), such as coronary artery disease and chronic heart failure with an increased risk of clinical events including sudden cardiac death. Diabetes mellitus and hypertension contribute to the development of CKD and the prevalence of CKD is in the range of 20%-65% in diabetic and 30%-50% in hypertensive patients. Therefore, prevention and optimal treatment of CV risk factors and comorbidities are key strategies to reduce CV risk and improve survival in CKD. Beyond common CV risk factors, patients with CKD are often physically inactive and have low physical function leading to subsequent frailty with muscle fatigue and weakness, sarcopenia and increased risk of falling. Consequently, the economic health burden of CKD is high, requiring feasible strategies to counteract this vicious cycle. Regular physical activity and exercise training have been shown to be effective in improving risk factors, reducing CVD and reducing frailty and falls. Nonetheless, combining exercise training and a healthy lifestyle with pharmacological treatment is not frequently applied in clinical practice. For that reason, this Clinical Consensus Statement reviews the current literature and provides evidence-based data regarding the role of exercise training in reducing CV and overall burden in patients with CKD. The aim is to increase awareness among cardiologists, nephrologists, and health care professionals of the potential of exercise therapy in order to encourage implementation of exercise training in clinical practice, eventually reducing CV risk and disease, as well as reducing frailty in patients with CKD G3 to G5D.

Bone mineral density after exercise training in patients with chronic kidney disease stages 3 to 5: a sub-study of RENEXC-a randomized controlled trial.

Background: We evaluated the effects of 12 months of exercise training on bone mineral density (BMD) in patients with chronic kidney disease (CKD) stages 3-5 not on kidney replacement therapy (KRT). Methods: A total of 151 patients were randomized to 12 months of either balance or strength training, both together with endurance training. Some 112 patients completed and 107 (69 men, 38 women) were analysed, with a mean age 66 ± 13.5 years and 31% having diabetes. The exercise training was self-administered, prescribed and monitored by a physiotherapist. Total body, hip and lumbar BMD, T score and Z score were measured at baseline and after 12 months using dual energy X-ray absorptiometry. Results: Both groups showed increased physical performance. The prevalence of osteoporosis and osteopenia was unchanged. The strength group (SG) decreased total body BMD (P < .001), the balance group (BG) increased total body T score (P < .05) and total body Z score (P < .005). Total body ΔT score was negative in the SG and unchanged in the BG (P < .005). Total body ΔZ score was negative in the SG and positive in the BG (P < .001). The proportion of progressors measured by ΔT (P < .05) and ΔZ scores (P < .05) was significantly lower in the BG compared with the SG. In multivariate logistic regression analysis, belonging to the BG was the only factor with a lower risk of deterioration of total body BMD, T and Z scores. Conclusions: Twelve months of balance training together with endurance training seemed to be superior to strength training in maintaining and improving BMD in patients with CKD not on KRT.

Needs, barriers and facilitators for a healthier lifestyle in haemodialysis patients: The GoodRENal project.

BACKGROUND: Malnutrition, sedentary lifestyle, cognitive dysfunction and poor psychological well-being are often reported in patients on haemodialysis (HD). AIMS: We aimed to explore needs, barriers and facilitators-as perceived by patients, their carers, and healthcare professionals (HCPs) for increasing the adherence to the diet, to physical activity and cognition and psychological well-being. METHODS: This is an observational cross-sectional study following the STROBE statement. This study is part of an ERASMUS+ project, GoodRENal-aiming to develop digital tools as an educational approach to patients on HD. For that, the GoodRENal comprises HD centers located in four Belgium, Greece, Spain and Sweden. Exploratory questionnaires were developed regarding the perceived needs, barriers and facilitators regarding the diet, physical activity, cognition and psychological well-being from the perspective of patients, their carers and HCPs. RESULTS: In total, 38 patients, 34 carers and 38 HCPs were included. Nutrition: For patients and carers, the main needs to adhere to the diet included learning more about nutrients and minerals. For patients, the main barrier was not being able to eat what they like. Physical activity: As needs it was reported information about type of appropriate physical activity, while fatigue was listed as the main barrier. For Cognitive and emotional state, it was perceived as positive for patients and carers perception but not for HCPs. The HCPs identified as needs working as a team, having access to specialised HCP and being able to talk to patients in private. CONCLUSIONS: Patients and their carers listed as needs guidance regarding nutrition and physical activity but were positive with their cognitive and emotional state. The HCPs corroborated these needs and emphasised the importance of teamwork and expert support.

First-year mortality in incident dialysis patients: results of the Peridialysis study.

BACKGROUND: Controversy surrounds which factors are important for predicting early mortality after dialysis initiation (DI). We investigated associations of predialysis course and circumstances affecting planning and execution of DI with mortality following DI. METHODS: Among 1580 patients participating in the Peridialysis study, a study of causes and timing of DI, we registered features of predialysis course, clinical and biochemical data at DI, incidence of unplanned suboptimal DI, contraindications to peritoneal dialysis (PD) or hemodialysis (HD), and modality preference, actual choice, and cause of modality choice. Patients were followed for 12 months or until transplantation. A flexible parametric model was used to identify independent factors associated with all-cause mortality. RESULTS: First-year mortality was 19.33%. Independent factors predicting death were high age, comorbidity, clinical contraindications to PD or HD, suboptimal DI, high eGFR, low serum albumin, hyperphosphatemia, high C-reactive protein, signs of overhydration and cerebral symptoms at DI. Among 1061 (67.2%) patients who could select dialysis modality based on personal choice, 654 (61.6%) chose PD, 368 (34.7%) center HD and 39 (3.7%) home HD. The 12-months survival did not differ significantly between patients receiving PD and in-center HD. CONCLUSIONS: First-year mortality in incident dialysis patients was in addition to high age and comorbidity, associated with clinical contraindications to PD or HD, clinical symptoms, hyperphosphatemia, inflammation, and suboptimal DI. In patients with a "free" choice of dialysis modality based on their personal preferences, PD and in-center HD led to broadly similar short-term outcomes.

Choice of dialysis modality among patients initiating dialysis: results of the Peridialysis study.

BACKGROUND: In patients with end-stage kidney disease (ESKD), home dialysis offers socio-economic and health benefits compared with in-centre dialysis but is generally underutilized. We hypothesized that the pre-dialysis course and institutional factors affect the choice of dialysis modality after dialysis initiation (DI). METHODS: The Peridialysis study is a multinational, multicentre prospective observational study assessing the causes and timing of DI and consequences of suboptimal DI. Clinical and biochemical data, details of the pre-dialytic course, reasons for DI and causes of the choice of dialysis modality were registered. RESULTS: Among 1587 included patients, 516 (32.5%) were judged unsuitable for home dialysis due to contraindications [384 ( 24.2%)] or no assessment [106 (6.7%); mainly due to late referral and/or suboptimal DI] or death [26 (1.6%)]. Older age, comorbidity, late referral, suboptimal DI, acute illness and rapid loss of renal function associated with unsuitability. Of the remaining 1071 patients, 700 (65.4%) chose peritoneal dialysis (61.7%) or home haemodialysis (HD; 3.6%), while 371 (34.6%) chose in-centre HD. Somatic differences between patients choosing home dialysis and in-centre dialysis were minor; factors linked to the choice of in-centre dialysis were late referral, suboptimal DI, acute illness and absence of a 'home dialysis first' institutional policy. CONCLUSIONS: Given a personal choice with shared decision making, 65.4% of ESKD patients choose home dialysis. Our data indicate that the incidence of home dialysis potentially could be further increased to reduce the incidence of late referral and unplanned DI and, in acutely ill patients, by implementing an educational programme after improvement of their clinical condition.

Exercise training in chronic kidney disease-effects, expectations and adherence.

There is increasing evidence showing the health benefits of physical activity, such as better survival and possibly even a slower decline in kidney function, in people with chronic kidney disease (CKD). There is convincing evidence that exercise training improves physical function measured as aerobic capacity, muscle endurance strength and balance at all ages and all stages of CKD. In fact, long-term adherence to well-designed and adequately monitored exercise training programmes is high. In general, patients express interest in exercise training and are motivated to improve their physical function and health. A growing number of nephrologists regard physical activity and exercise training as beneficial to patients with CKD. However, many feel that they do not have the knowledge to prescribe exercise training and suppose that patients are not interested. Patients state that support from healthcare professionals is crucial to motivate them to participate in exercise training programmes and overcome medical, physical and psychological barriers such as frailty, fatigue, anxiety and fear. Equally important is the provision of funding by healthcare providers to ensure adequate prescription and follow-up by trained exercise physiologists for this important non-pharmacological treatment.

Suboptimal dialysis initiation is associated with comorbidities and uraemia progression rate but not with estimated glomerular filtration rate.

BACKGROUND: Despite early referral of uraemic patients to nephrological care, suboptimal dialysis initiation (SDI) remains a common problem associated with increased morbimortality. We hypothesized that SDI is related to pre-dialysis care. METHODS: In the 'Peridialysis' study, time and reasons for dialysis initiation (DI), clinical and biochemical data and centre characteristics were registered during the pre- and peri-dialytic period for 1583 end-stage kidney disease patients starting dialysis over a 3-year period at 15 nephrology departments in the Nordic and Baltic countries to identify factors associated with SDI. RESULTS: SDI occurred in 42%. Risk factors for SDI were late referral, cachexia, comorbidity (particularly cardiovascular), hypoalbuminaemia and rapid uraemia progression. Patients with polycystic renal disease had a lower incidence of SDI. High urea and C-reactive protein levels, acidosis and other electrolyte disorders were markers of SDI, independently of estimated glomerular filtration rate (eGFR). SDI patients had higher eGFR than non-SDI patients during the pre-dialysis period, but lower eGFR at DI. eGFR as such did not predict SDI. Patients with comorbidities had higher eGFR at DI. Centre practice and policy did not associate with the incidence of SDI. CONCLUSIONS: SDI occurred in 42% of all DIs. SDI was associated with hypoalbuminaemia, comorbidity and rate of eGFR loss, but not with the degree of renal failure as assessed by eGFR.

Muscle mass and plasma myostatin after exercise training: a substudy of Renal Exercise (RENEXC)-a randomized controlled trial.

BACKGROUND: Sarcopenia increases as renal function declines and is associated with higher morbidity and mortality. Myostatin is a negative regulator of muscle growth. Its expression in response to exercise is unclear. In this prespecified substudy of the Renal Exercise (RENEXC) trial, we investigated the effects of 12 months of exercise training on sarcopenia, muscle mass and plasma myostatin and the relationships between physical performance, muscle mass and plasma myostatin. METHODS: A total of 151 non-dialysis-dependent patients (average measured glomerular filtration rate 23 ± 8 mL/min/1.73 m2), irrespective of age or comorbidity, were randomly assigned to either strength or balance in combination with endurance training. Body composition was measured with dual-energy X-ray absorptiometry. Plasma myostatin was analysed using enzyme-linked immunosorbent assay kits. RESULTS: After 12 months, the prevalence of sarcopenia was unchanged, leg and whole-body lean mass increased significantly in the balance group and was unchanged in the strength group. Whole fat mass decreased significantly in both groups. There were no significant between-group differences in sarcopenia or body composition. Plasma myostatin levels increased significantly in both groups, with a significant difference in favour of the strength group. Plasma myostatin was significantly positively related to muscle mass and physical performance at baseline, but these relationships were attenuated after 12 months. CONCLUSIONS: Exercise training seems to be effective in preventing sarcopenia and maintaining muscle mass in non-dialysis-dependent patients with chronic kidney disease (CKD). However, the role of plasma myostatin on muscle mass and physical performance in patients with CKD warrants further study.

Twelve months of exercise training did not halt abdominal aortic calcification in patients with CKD - a sub-study of RENEXC-a randomized controlled trial.

BACKGROUND: Arteriosclerosis is prevalent in patients with chronic kidney disease (CKD). Our aims were to investigate (1) the effects of 12 months of either balance- or strength- both in combination with endurance training on abdominal aortic calcification (AAC); on some lipids and calcific- and inflammatory markers; and (2) the relationships between the change in AAC score and these markers in non-dialysis dependent patients with CKD stages 3 to 5. METHODS: One hundred twelve patients (mean age 67 ± 13 years), who completed 12 months of exercise training; comprising either balance- or strength training, both in combination with endurance training; with a measured glomerular filtration rate (mGFR) 22.6 ± 8 mL/min/1.73m2, were included in this study. AAC was evaluated with lateral lumbar X-ray using the scoring system described by Kauppila. Plasma fetuin-A, fibroblast growth factor 23 (FGF23) and interleukin 6 (IL6) were measured with Enzyme-linked immunosorbent assay (ELISA) kits. RESULTS: After 12 months of exercise training, the AAC score increased significantly in both groups; mGFR and lipoprotein (a) decreased significantly in both groups; parathyroid hormone (PTH) and 1,25(OH)2D3 increased significantly only in the strength group; fetuin-A increased significantly only in the balance group. Plasma triglycerides, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, FGF23, phosphate, calcium, IL6, C-reactive protein (CRP), albumin were unchanged. The increase in AAC score was positively related to ageing and the levels of baseline triglycerides and lipoprotein (a). CONCLUSIONS: Exercise training did not prevent the progression of AAC; it might have contributed to the reduced levels of lipoprotein (a) and unchanged levels of calcific- and inflammatory markers in these patients with non-dialysis dependent CKD. Hypertriglyceridemia, high levels of lipoprotein (a) and ageing emerged as longitudinal predictors of vascular calcification in these patients. TRIAL REGISTRATION: NCT02041156 at www.ClinicalTrials.gov. Date of registration: January 20, 2014. Retrospectively registered.

The treatment of renal hyperparathyroidism.

Renal hyperparathyroidism (rHPT) is a complex and challenging disorder. It develops early in the course of renal failure and is associated with increased risks of fractures, cardiovascular disease and death. It is treated medically, but when medical therapy cannot control the hyperparathyroidism, surgical parathyroidectomy is an option. In this review, we summarize the pathophysiology, diagnosis, and medical treatment; we describe the effects of renal transplantation; and discuss the indications and strategies in parathyroidectomy for rHPT. Renal hyperparathyroidism develops early in renal failure, mainly as a consequence of lower levels of vitamin D, hypocalcemia, diminished excretion of phosphate and inability to activate vitamin D. Treatment consists of supplying vitamin D and reducing phosphate intake. In later stages calcimimetics might be added. RHPT refractory to medical treatment can be managed surgically with parathyroidectomy. Risks of surgery are small but not negligible. Parathyroidectomy should likely not be too radical, especially if the patient is a candidate for future renal transplantation. Subtotal or total parathyroidectomy with autotransplantation are recognized surgical options. Renal transplantation improves rHPT but does not cure it.

Randomized Controlled Trial of Exercise in CKD-The RENEXC Study.

INTRODUCTION: Home-based, clinically feasible trials in non-dialysis-dependent patients with chronic kidney disease (CKD) are sparse. We compared the effects of 2 different exercise training programs on physical performance, and measured glomerular filtration rate (mGFR) and albuminuria level in patients with CKD stages 3 to 5. METHODS: This is a single-center, randomized controlled trial (RCT) comprising 151 patients (mGFR: 22 ± 8 ml/min per 1.73 m2; age 66 ± 14 years) randomized to either balance or strength training. Both groups were prescribed 30 minutes of exercise per day for 5 days per week for 12 months, comprising 60 minutes per week of endurance training and 90 minutes per week of either strength or balance exercises. The exercises were individually prescribed, and the intensity was monitored with Borg's rating of perceived exertion (RPE). RESULTS: There were no treatment differences for any of the primary outcomes measuring physical performance. The strength and balance groups showed significantly increased effect sizes after 12 months for the following: walking (31 m and 24 m, P < 0.001) and the 30-second sit-to-stand test (both: 1 time, P < 0.001); quadriceps strength (right/left: strength 1.2/0.8 kg*m, P < 0.003; balance 0.6/0.9, P < 0.01); functional reach (both: 2 cm, P < 0.01); and fine motor skills (open/closed eyes, right/left, both: between 0.3 and 4 seconds faster, P < 0.05). After 12 months, there was a significant treatment difference for albuminuria (P < 0.02), which decreased by 33% in the strength group. In both groups, mGFR declined by 1.8 ml/min per 1.73 m2. CONCLUSION: Our primary hypothesis that strength training was superior to balance training was not confirmed. Within groups, 12 months of exercise training resulted in significant improvements in most measures of physical performance. Measured GFR declined similarly in the 2 groups. The strength group showed a significant decrease in albuminuria.

Cardiovascular and Cerebrovascular Events After Parathyroidectomy in Patients on Renal Replacement Therapy.

BACKGROUND: A majority of patients with end-stage renal disease suffer from secondary hyperparathyroidism, which is associated with osteoporosis and cardiovascular disease. Parathyroidectomy (PTX) is often necessary despite medical treatment. However, the effect of PTX on cardio- and cerebrovascular events (CVE) remains unclear. Data on the effect of PTX from population-based studies are scarce. Some studies have shown decreased incidence of CVE after PTX. The aim of this study was to evaluate the effect of PTX on risk of CVE in patients on renal replacement therapy. METHODS: We performed a nested case-control study within the Swedish Renal Registry (SRR) by matching PTX patients on dialysis or with functioning renal allograft with up to five non-PTX controls for age, sex and underlying renal disease. To calculate time to CVE, i.e., myocardial infarct, stroke and transient ischemic attack, control patients were assigned the calendar date (d) of the PTX of the case patient. Crude and adjusted proportional hazards regressions with random effect (frailty) were used to calculate hazard ratios for CVE. RESULTS: The study cohort included 20,056 patients in the SRR between 1991 and 2009. Among these, 579 patients had undergone PTX, 423 during dialysis and 156 during time with functioning renal allograft. These patients were matched with 1234 dialysis and 736 transplanted non-PTX patients. The adjusted hazard ratio (HR) with 95% confidence interval (CI) of CVE after PTX was 1.24 (1.03-1.49) for dialysis patients compared with non-PTX patients. Corresponding results for patients with renal allograft at d were HR (95% CI) 0.53 (0.34-0.84). CONCLUSIONS: PTX patients on dialysis at d had a higher risk of CVE than patients without PTX. Patients with renal allograft at d on the other had a lower risk after PTX than patients without PTX.

Improved long-term survival with home hemodialysis compared with institutional hemodialysis and peritoneal dialysis: a matched cohort study.

BACKGROUND: The survival rate for dialysis patients is poor. Previous studies have shown improved survival with home hemodialysis (HHD), but this could be due to patient selection, since HHD patients tend to be younger and healthier. The aim of the present study is to analyse the long-term effects of HHD on patient survival and on subsequent renal transplantation, compared with institutional hemodialysis (IHD) and peritoneal dialysis (PD), taking age and comorbidity into account. METHODS: Patients starting HHD as initial renal replacement therapy (RRT) were matched with patients on IHD or PD, according to gender, age, Charlson Comorbidity Index and start date of RRT, using the Swedish Renal Registry from 1991 to 2012. Survival analyses were performed as intention-to-treat (disregarding changes in RRT) and per-protocol (as on initial RRT). RESULTS: A total of 152 patients with HHD as initial RRT were matched with 608 IHD and 456 PD patients, respectively. Median survival was longer for HHD in intention-to-treat analyses: 18.5 years compared with 11.9 for IHD (p <  0.001) and 15.0 for PD (p = 0.002). The difference remained significant in per-protocol analyses omitting the contribution of subsequent transplantation. Patients on HHD were more likely to receive a renal transplant compared with IHD and PD, although treatment modality did not affect subsequent graft survival (p > 0.05). CONCLUSION: HHD as initial RRT showed improved long-term patient survival compared with IHD and PD. This survival advantage persisted after matching and adjusting for a higher transplantation rate. Dialysis modality had no impact on subsequent graft survival.

Fewer hospitalizations and prolonged technique survival with home hemodialysis- a matched cohort study from the Swedish Renal Registry.

BACKGROUND: Patients on home hemodialysis (HHD) exhibit superior survival compared with patients on institutional hemodialysis (IHD) and peritoneal dialysis (PD). There is a sparsity of reports comparing morbidity between HHD and IHD or PD and none in a European population. The aim of this study is to compare morbidity between modalities in a Swedish population. METHODS: The Swedish Renal Registry was used to retrieve patients starting on HHD, IHD or PD. Patients were matched according to sex, age, comorbidity and start date. The Swedish Inpatient Registry was used to determine comorbidity before starting renal replacement therapy (RRT) and hospital admissions during RRT. Dialysis technique survival was compared between HHD and PD. RESULTS: RRT was initiated with HHD for 152 patients; these were matched with 608 patients with IHD and 456 with PD. Patients with HHD had significantly lower annual admission rate and number of days in hospital. (median 1.7 admissions; 12 days) compared with IHD (2.2; 14) and PD (2.8; 20). The annual admission rate was significantly lower for patients with HHD compared with IHD for cardiovascular diagnoses and compared with PD for infectious disease diagnoses. Dialysis technique survival was significantly longer with HHD compared with PD. CONCLUSIONS: Patients choosing HHD as initial RRT spend less time in hospital compared with patients on IHD and PD and they were more likely than PD patients, to remain on their initial modality. These advantages, in combination with better survival and higher likelihood of renal transplantation, are important incentives for promoting the use of HHD.

Comparison of DEXA and Bioimpedance for Body Composition Measurements in Nondialysis Patients With CKD.

OBJECTIVES: The aims of this study are (1) to compare dual-energy X-ray absorptiometry (DEXA) and bioimpedance for body composition measurements in nondialysis patients with chronic kidney disease, and (2) to investigate factors associated with any measurement differences. DESIGN AND METHODS: This is a substudy using some baseline data from a randomized controlled clinical trial. One hundred twenty patients (aged 65 ± 14 years) with a measured glomerular filtration rate 8 to 55 mL/min/1.73m2, not on renal replacement therapy, irrespective of age and number of comorbidities, were included from 2011 to 2016. For DEXA measurements, Lunar Prodigy or Lunar iDXA were used. For bioimpedance measurements, body composition monitor (BCM) was used. Glomerular filtration rate was measured with iohexol clearance. Data were analyzed using R software. Bland-Altman analysis was performed to compare the 2 measurements. The measurement difference was DEXA minus BCM. Multiple linear regression analysis was performed to analyze relationships between variables. RESULTS: The estimation of fat-free mass was higher using BCM than DEXA, with a mean difference of -2.8 kg and limits of agreement (mean ± 2 SD) ranging from -12 kg to 6.5 kg. The estimation of fat mass was lower using BCM than DEXA, with a mean difference of 3.1 kg and limits of agreement (mean ± 2 SD) ranging from -6.8 kg to 13 kg. The measurement differences were significantly related to lean tissue index, fat tissue index, extracellular water, intracellular water, extracellular water/intracellular water, total body water, and overhydration. CONCLUSION: Our study showed a limited agreement between DEXA and bioimpedance, indicating that these 2 measurements are not interchangeable in nondialysis patients with chronic kidney disease. Lean tissue index, fat tissue index, and body water might contribute to the measurement differences, while measured glomerular filtration rate is not a factor associated with the measurement differences for body composition. Thus, we suggest that the same measure of body composition be used over time.

Total versus subtotal parathyroidectomy for secondary hyperparathyroidism.

BACKGROUND: It remains unclear whether total or subtotal parathyroidectomy for secondary hyperparathyroidism yields the best outcomes. We investigated mortality, cardiovascular events, hip fracture, and recurrent parathyroidectomy after total versus subtotal parathyroidectomy in patients on renal replacement therapy. METHODS: Using the Swedish Renal Registry, the surgical registry for thyroid and parathyroid surgery, and the National Inpatient Registry, we identified patients who underwent parathyroidectomy between 1991 and 2013. We calculated the risk of outcome after total versus subtotal parathyroidectomy using COX's regression, adjusting for age, sex, cause of renal disease, time with a functioning graft before and after parathyroidectomy, Charlson comorbidity index, year of surgery, prevalent cardiovascular disease, time on dialysis, renal transplantation at parathyroidectomy, and treatment with calcimimetics before parathyroidectomy. RESULTS: There were 824 patients who underwent parathyroidectomy, 388 total and 436 subtotal. There was no difference in mortality or risk of incident hip fracture between groups. Comparing the subtotal with the total parathyroidectomy, the adjusted hazard ratio (95% confidence interval) for cardiovascular events was 0.43 (0.25-0.72) and for recurrent parathyroidectomy 3.33 (1.33-8.32). CONCLUSION: There was a higher risk of cardiovascular events in patients after total parathyroidectomy compared with subtotal parathyroidectomy, but a lower risk of recurrent parathyroidectomy.

Comparing effects of 4 months of two self-administered exercise training programs on physical performance in patients with chronic kidney disease: RENEXC - A randomized controlled trial.

BACKGROUND: Exercise training is recommended to patients with chronic kidney disease (CKD). However, the level of evidence is still low. This randomized controlled trial (RCT) compared two different and self-administered exercise training programs in a representative CKD population. METHODS: This single centre RCT included 151 non-dialysis dependent CKD patients, irrespective of age and comorbidity. Self-administered exercise training of 150 minutes per week was prescribed for 4 months and consisted of 60 minutes endurance training in combination with 90 minutes of either strength or balance training (strength versus balance group). Overall endurance (6-minute walk-test (6-MWT), stair climbing), muscular endurance (30-seconds sit-to-stand (30-STS), heel rises and toe lifts, handgrip (HGS) and isometric quadriceps (IQS) strength, balance (functional reach (FR) and Berg´s balance scale (BBS)) and fine motor skills (Moberg´s picking up test (MPUT)) were measured at baseline and after 4 months. Intention to treat analyses with mixed models was used. RESULTS: 53 women and 98 men, mean age 66 ± 14: range 19 to 87 years, eGFR 20 ± 7: range 8 to 48 ml/min/1.73m2 participated. The strength group (n = 76) improved significantly in 6-MWT, stair climbing, 30-STS, heel rises right and left, toe lifts right, IQS right and left, and MPUT with closed eyes with the right and left hand. The balance group (n = 75) improved significantly in heel rises right and left, IQS left, BBS and left-handed MPUT with open and closed eyes. A significant effect between the groups was found for IQS right. CONCLUSIONS: Two different exercise training programs, consisting of endurance in combination with either strength or balance exercise training, improved or maintained overall endurance, muscular strength and endurance, balance and fine motor skills after 4 months of 150 minutes/week self-administered exercise training in a representative CKD population, regardless of age and comorbidity.