Results From a Physical Activity Intervention Feasibility Study With Kidney Inpatients.

BACKGROUND: Individuals with end-stage kidney disease requiring dialysis are often physically inactive, resulting in reduced physical functioning, increased frailty, and reduced quality of life. Furthermore, extended hospital stays and frequent readmissions are common, exacerbating health care costs. Physical activity may improve physical functioning, disability, and frailty but is not part of standard care of patients requiring dialysis. Research is required to determine the feasibility of implementing physical function assessments and physical activity programs in kidney inpatients requiring dialysis. OBJECTIVE: To assess the feasibility and preliminary efficacy of an early-physical activity intervention (Move More study) in the care of kidney inpatients requiring dialysis. It was hypothesized that the intervention would be feasible with regards to administration and participation, meeting a priori feasibility criteria, and that kidney inpatients would benefit from participating. DESIGN: Pilot study. SETTING: Patient Unit 37, Foothills Medical Center, Calgary, AB, Canada. PATIENTS: Kidney in-patients receiving dialysis. MEASUREMENTS: Feasibility data were collected for recruitment, participation, assessment completion, physical activity completion, and adverse events. Participant and healthcare practitioner (HCP) satisfaction with the intervention was assessed using a questionnaire. Frailty and physical function were assessed by the kinesiologist at baseline and postintervention prior to hospital discharge. METHODS: The study was a single-arm pilot intervention examining feasibility and preliminary efficacy. Kidney inpatients requiring dialysis were recruited to an individualized in-hospital physical activity intervention for the duration of their hospital stay. The intervention was led by a kinesiologist and supported by the clinical care team, including physiotherapists and nurse clinicians. Individualized exercise programs were created for patients to perform daily during their stay. These programs focused on strength, mobility, balance, and general movement and were tailored to each patient's needs. RESULTS: Thirty-six percent of eligible patients (n = 23/64) consented to participate in the Move More study, of whom 78% (n = 18/23) completed the intervention. The a priori level for consent to participate in the intervention was set at 60%. In addition, the a priori level for completion of assessments pre and postintervention was 50%. Ninety-five percent (n = 22/23) of preintervention assessments were completed compared to 65% of postintervention assessments. All participants who completed the survey (100%, n = 14/14) and most of the staff (77%, n = 24/31) reported being satisfied or very satisfied with the program. There were no adverse events related to the intervention. On average, Move More patients demonstrated improvements in frailty status and specific subsets of quality of life. LIMITATIONS: Firstly, as a feasibility study, the research was not powered to address the effectiveness of the intervention and lacked a comparison group to definitively link observed changes to the intervention itself. The voluntary nature of recruitment may have been biased toward ESKD inpatients with above-average motivation and baseline function. Furthermore, the small sample size from a single site limits the generalizability of findings. An additional limitation was the fact that postassessments were missed on a large number of patients, due to them being discharged prior to research staff knowing and being able to complete the assessments. Finally, studying the length of stay across the institution, as opposed to just the individual ward, would provide insight into hospitalization impact for these patients. CONCLUSIONS: The administration of and participation in a physical activity intervention for kidney inpatients requiring dialysis was initially not feasible primarily due to low recruitment and adherence challenges. The study was modified by including a research team member on the unit to increase recruitment efforts and support exercise adherence. The intervention impact includes potentially benefits on frailty and quality of life.

CONTEXTE: Les personnes atteintes d'insuffisance rénale terminale (IRT) nécessitant une dialyze sont souvent inactives physiquement, ce qui entraîne une réduction du fonctionnement physique, une fragilité accrue et une diminution de la qualité de vie. De plus, les séjours prolongés à l'hôpital et les réadmissions fréquentes sont courants chez ces patients, ce qui accroît les coûts des soins de santé. L'activité physique peut améliorer le fonctionnement physique et réduire les incapacités et la fragilité, mais elle ne fait pas partie des soins courants prodigués aux patients nécessitant une dialyze. Des recherches sont nécessaires pour déterminer la faisabilité de la mise en œuvre d'évaluations du fonctionnement physique et de programs d'activité physique chez les patients hospitalisés atteints de néphropathie nécessitant une dialyze. OBJECTIFS: Évaluer la faisabilité et l'efficacité préliminaire d'une intervention précoce en matière d'activité physique (l'étude Move More) intégrée aux soins prodigués aux patients hospitalisés atteints d'insuffisance rénale et nécessitant une dialyze. L'hypothèse était que l'intervention serait réalisable en ce qui concerne l'administration et la participation, qu'elle répondrait aux critères de faisabilité a priori, et que les patients hospitalisés bénéficieraient d'une participation. TYPE D'ÉTUDE: Étude pilote. CADRE: L'unité de soins 37 du Foothills Medical Center de Calgary (Alberta) au Canada. SUJETS: Des patients hospitalisés recevant des traitements de dialyze. MESURES: Les données de faisabilité ont été recueillies pour le recrutement, la participation, l'achèvement de l'évaluation, l'achèvement du program d'activité physique et les événements indésirables. La satisfaction des participants et des professionnels de la santé à l'égard de l'intervention a été évaluée à l'aide d'un questionnaire. La fragilité et les fonctions physiques ont été évaluées avant et après l'intervention, et avant la sortie de l'hôpital. MÉTHODOLOGIE: L'étude était une intervention pilote à bras unique examinant la faisabilité et l'efficacité préliminaire. Les patients hospitalisés atteints d'insuffisance rénale et nécessitant une dialyze ont été recrutés pour une intervention individualisée d'activité physique pendant toute la durée de leur séjour à l'hôpital. L'intervention était dirigée par un kinésiologue et appuyée par l'équipe de soins cliniques qui comprenait notamment des physiothérapeutes et des infirmières cliniciennes. Des programs d'activité physique individualisés ont été créés afin que les patients puissent s'exercer quotidiennement pendant leur séjour. Ces programs étaient axés sur la force, la mobilité, l'équilibre et le mouvement général, et étaient adaptés aux besoins de chaque patient. RÉSULTATS: Trente-six pour cent des patients admissibles (n=23/64) ont consenti à participer à l'étude Move More; de ceux-ci, 78 % (n=18/23) ont complété l'intervention. Le niveau a priori de consentement à participer à l'intervention a été fixé à 60 % et celui de l'achèvement des évaluations avant et après l'intervention à 50 %. Quatre-vingt-quinze pour cent (n=22/23) des évaluations pré-intervention ont été effectuées, comparativement à 65 % pour les évaluations postintervention. Tous les participants qui ont répondu au sondage (100 %; n=14/14) et la majorité du personnel (77 %; n=24/31) interrogé ont déclaré être satisfaits ou très satisfaits du program. Aucun événement indésirable lié à l'intervention n'a été signalé. En moyenne, les patients de Move More ont montré des améliorations de leur état de fragilité et de sous-ensembles propres à la qualité de vie. LIMITES: Puisqu'il s'agit d'une étude de faisabilité, la recherche n'avait pas la puissance nécessaire pour évaluer l'efficacité de l'intervention et ne disposait pas de groupe de comparaison permettant d'établir un lien définitif entre les changements observés et l'intervention elle-même. La nature volontaire du recrutement pourrait avoir favorisé les patients hospitalisés atteints d'IRT ayant une motivation et une fonction de base supérieures à la moyenne. L'échantillon de petite taille, provenant d'un seul site, limite la généralisabilité des résultats. De plus, les évaluations postintervention ont été manquées pour un grand nombre de patients, ceux-ci ayant obtenu leur congé avant que le personnel de recherche ait été avisé ou en mesure de compléter les évaluations. Enfin, le fait de connaître la durée du séjour dans l'ensemble de l'établissement, et non seulement dans chaque service permettrait de mieux comprendre l'impact de l'hospitalization pour ces patients. CONCLUSION: L'exécution d'une intervention d'activité physique et la participation des patients hospitalisés nécessitant une dialyze à une telle intervention n'étaient pas réalisables initialement, principalement en raison de difficultés liées au recrutement et à l'observance. L'étude a été modifiée pour intégrer un membre de l'équipe de recherche dans l'unité de soins afin d'accroître les efforts de recrutement et de soutenir l'observance du program d'exercices. L'impact de l'intervention comprend des avantages potentiels sur la fragilité et la qualité de vie.

Global Policy Barriers and Enablers to Exercise and Physical Activity in Kidney Care.

OBJECTIVE: Impairment in physical function and physical performance leads to decreased independence and health-related quality of life in people living with chronic kidney disease and end-stage kidney disease. Physical activity and exercise in kidney care are not priorities in policy development. We aimed to identify global policy-related enablers, barriers, and strategies to increase exercise participation and physical activity behavior for people living with kidney disease. DESIGN AND METHODS: Guided by the Behavior Change Wheel theoretical framework, 50 global renal exercise experts developed policy barriers and enablers to exercise program implementation and physical activity promotion in kidney care. The consensus process consisted of developing themes from renal experts from North America, South America, Continental Europe, United Kingdom, Asia, and Oceania. Strategies to address enablers and barriers were identified by the group, and consensus was achieved. RESULTS: We found that policies addressing funding, service provision, legislation, regulations, guidelines, the environment, communication, and marketing are required to support people with kidney disease to be physically active, participate in exercise, and improve health-related quality of life. We provide a global perspective and highlight Japanese, Canadian, and other regional examples where policies have been developed to increase renal physical activity and rehabilitation. We present recommendations targeting multiple stakeholders including nephrologists, nurses, allied health clinicians, organizations providing renal care and education, and renal program funders. CONCLUSIONS: We strongly recommend the nephrology community and people living with kidney disease take action to change policy now, rather than idly waiting for indisputable clinical trial evidence that increasing physical activity, strength, fitness, and function improves the lives of people living with kidney disease.

An International Delphi Survey on Exercise Priorities in CKD.

INTRODUCTION: Defining the role of exercise in chronic kidney disease (CKD) is a top research priority for people with CKD. We aimed to achieve consensus on specific research priorities in exercise and CKD among an international panel of stakeholders. METHODS: Using the Delphi method, patients/caregivers, researchers, clinicians, and policymakers submitted their top research priorities in round 1 and ranked their importance in rounds 2 and 3 using a 9-point Likert scale. The mean, median, and proportion of scores ranked 7 to 9 were calculated. Consensus was defined as priorities that scored above the overall mean and median score within each stakeholder panel. Qualitative description was used to understand participants' rankings. RESULTS: Seventy participants (78% response) completed round 1: 15 (21.4%) clinicians, 33 (47.1%) researchers, 13 (18.6%) policymakers, and 9 (12.9%) patients; (85.7%) completed round 3. The top research priorities were defining exercise-related outcomes meaningful to patients, identifying patients' motivation and perspective towards exercise, understanding the effect of exercise on the risk of institutionalization, mortality, and mobility, and understanding the effect of pre- and post-transplant exercise on postoperative recovery. Themes from the qualitative analysis were individualization, personal experience, and holistic approach to exercise (patients), the need to address common clinical problems (clinicians), developing targeted interventions (researchers), and the importance of evidence-based development versus implementation (policymakers). CONCLUSIONS: Preventing physical disability was a common priority. Policymakers emphasized that more efficacy studies were needed. Other panels expressed the need for holistic and targeted exercise interventions and for outcomes that address common clinical problems.

A Physical Activity Intervention Feasibility Study for Kidney Inpatients: A Basic Research Protocol.

BACKGROUND: Low physical activity levels and poor physical functioning are strongly associated with poor clinical outcomes and mortality in adult kidney failure patients, regardless of treatment modality. Compared with the general population, individuals with chronic kidney disease are physically inactive, have reduced physical abilities and difficulties performing routine daily tasks, lower health-related quality of life, and higher cardiovascular morbidity and mortality. In addition, frail kidney failure patients have higher hospitalization and mortality rates as compared with other kidney failure patients. Evidence suggests that assessment and recommendations for physical activity should be part of standard care for kidney failure patients. Structured exercise can improve physical function and quality of life in frail older adults and may be used specifically for management of frailty in kidney failure. However, research is needed to determine best practices for implementation of physical function measurements and physical activity promotion in standard kidney failure care. OBJECTIVE: The proposed Move More study will assess the feasibility of a physical activity intervention offered to the kidney failure inpatients in Calgary, Alberta. Specifically, this study is designed to examine the effects of an early physical activity/mobility intervention led by a kinesiologist, and supported by the clinical care team including physiotherapists (PT) and nurse clinicians. METHODS: The Move More study is a single-arm pilot intervention examining feasibility and optimal improvement in real-world conditions. Kidney failure inpatients at the Foothills Medical Centre will be recruited to participate. Patients will receive an individualized in-hospital physical activity/mobility intervention. Frailty and physical function will be assessed at baseline and postintervention prior to hospital discharge. The goal is to recruit 24 to 36 patients. CONCLUSIONS: Evidence needed to support the inclusion of mobility and physical activity as part of standard care will be gathered, with knowledge gained used to help direct future physical activity programming for kidney failure inpatients.

CONTEXTE: Un faible niveau d'activité physique et une santé physique hypothéquée sont fortement associés à de mauvais résultats cliniques et à la mortalité chez les adultes atteints d'insuffisance rénale terminale (IRT), quelle que soit la modalité de traitement. Comparativement à la population générale, les personnes atteintes d'IRT sont moins actives, ont des capacités physiques réduites, ont davantage de difficulté à accomplir leurs tâches quotidiennes, ont une plus faible qualité de vie liée à la santé, et présentent des taux plus élevés de morbidité et de mortalité associées aux maladies cardiovasculaires. Par ailleurs, les patients physiquement fragiles qui souffrent d'IRT présentent des taux d'hospitalisation et de mortalité plus élevés que les autres patients atteints d'IRT. Les données indiquent qu'une évaluation des fonctions physiques et des recommandations en matière d'activité physique devraient faire partie des soins courants prodigués aux patients souffrant d'IRT. Un programme d'exercice structuré est susceptible d'améliorer la santé physique et la qualité de vie des personnes âgées fragiles, et pourrait être utilisé précisément pour gérer la fragilité en contexte d'IRT. Des recherches sont cependant nécessaires pour cerner les meilleures pratiques à adopter pour mettre en œuvre des mesures évaluant la fonction physique et faire la promotion de l'activité physique dans le cadre des soins courants prodigués en contexte d'IRT. OBJECTIFS: L'étude Move More proposée évaluera la faisabilité d'une intervention favorisant l'activité physique qui sera offerte aux patients hospitalisés souffrant d'IRT à Calgary, en Alberta. Plus précisément, cette étude est conçue pour examiner les effets d'une intervention précoce en matière d'activité physique et de mobilité, dirigée par un kinésiologue et appuyée par une équipe de soins cliniques composée de physiothérapeutes (PT) et d'infirmières cliniciennes. MÉTHODOLOGIE: L'étude Move More est une intervention pilote à bras unique qui examinera la faisabilité et l'amélioration optimale en conditions réelles. Les patients avec IRT au centre médical Foothills seront recrutés pour participer à l'étude. Les patients bénéficieront d'un programme individualisé d'activité physique/mobilité à l'hôpital. La fragilité et les fonctions physiques seront évaluées avant et après l'intervention, avant la sortie de l'hôpital. L'objectif est de recruter entre 24 et 36 patients. CONCLUSIONS: Les preuves nécessaires pour appuyer l'inclusion d'une intervention visant la mobilité et l'activité physique aux soins courants seront rassemblées. Les connaissances acquises serviront à orienter de futurs programmes d'activité physique destinés aux patients hospitalisés souffrant d'IRT.

Conservative management of an iatrogenic arteriovenous fistula.

BACKGROUND: Arteriovenous fistula is an uncommon complication of central venous catheterization that often requires invasive repair. CASE REPORT: We report the case of an arteriovenous fistula that presented as ongoing pain following removal of a tunneled central venous catheter. The fistula resolved spontaneously following a period of compression and observation. CONCLUSION: Our study highlights the etiology of this uncommon complication as well as suggesting a role for conservative management.

The Duke Activity Status Index in patients with chronic kidney disease: a reliability study.

BACKGROUND AND OBJECTIVES: Exercise capacity is impaired at a younger age in CKD patients than in the general population. This study examined the reliability of the Duke Activity Status Index (DASI) questionnaire as a measure of exercise capacity in medically stable adults with stage 3-4 CKD (estimated GFR [eGFR], 15-59 ml/min per 1.73 m(2)). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Peak oxygen uptake (VO(2)peak), estimated from DASI responses and cardiopulmonary exercise test measurements, was obtained at baseline and 6 months in a derivation sample (n=23) and once in a validation sample (n=20). Bland-Altman analysis and linear mixed models were used to estimate bias, concordance correlation coefficients, and intraclass correlation coefficients as the proportion of the variance due to participant (intertest reliability) and method (test-retest reliability). RESULTS: The two samples were homogeneous with respect to age (mean 60 ± 14 years), eGFR (35.5 ± 15 ml/min per 1.73 m(2)), male sex (53%), and diabetes (56%). Mean measured VO(2)peak was 16.5 ± 4 ml/kg per min. The DASI questionnaire overestimated VO(2)peak by 4.3 ml/kg per min. Intertest reliability was 53% when eGFR was ≥35 ml/min per 1.73 m(2) (median) and 60% when eGFR was <35 ml/min per 1.73 m(2) (P<0.01). Test-retest reliability was 81% when eGFR was <35 ml/min per 1.73 m(2) and 71% when eGFR was ≥35 ml/min per 1.73 m(2) (P<0.01). CONCLUSIONS: The DASI questionnaire may be a reliable measure of exercise capacity in CKD patients, especially when eGFR is <35 ml/min per 1.73 m(2). Larger prospective studies are needed to determine its prognostic value.

Effects of exercise training on physical impairment, arterial stiffness and health-related quality of life in patients with chronic kidney disease: a pilot study.

BACKGROUND: Patients with chronic kidney disease (CKD) have impaired performance in physical tasks, lower health-related quality of life and high cardiovascular morbidity and mortality. Moderate intensity exercise has been shown to provide cardiovascular and metabolic benefits in healthy individuals and patients without CKD. Long-term exercise training is recommended as a vital component in the management of a number of chronic diseases. This randomized controlled pilot project examined the effects of exercise in predialysis CKD patients. METHODS: Ten patients were randomized to 12 months of exercise (EX) and 10 to standard care (CT). We compared the difference between the two groups in physical impairment (VO(2peak) and endurance time [ET]), arterial stiffness (augmentation index [AI]) and health-related quality of life (EuroQol EQ-5D and Short Form-36 questionnaires) (all measured at baseline and 12 months). RESULTS: The difference between EX and CT was statistically significant for VO(2peak) (3.59 ml O(2)/kg/min; 95% CI 0.92, 6.26; P = 0.01), ET (10.97 min; 95% CI 4.34, 17.59; P = 0.003) and AI (-11.7%; 95% CI -18.79, -4.61; P = 0.003). Clinically important changes were noted in EQ-5D and SF-36. CONCLUSIONS: This study suggests that long-term exercise training improves physical impairment, arterial stiffness and health-related quality of life in patients with predialysis CKD. A larger randomized trial is required to examine the impact of exercise on markers of cardiovascular risk and quality of life in predialysis CKD patients.

Impact of an exercise program on arterial stiffness and insulin resistance in hemodialysis patients.

Cardiovascular disease remains the primary cause of mortality in patients who are maintained on hemodialysis. Arterial stiffness and insulin resistance are independent risk factors for cardiovascular mortality in this population. In healthy individuals, higher physical conditioning is associated with reduced arterial stiffness. Exercise reduces insulin resistance and glucose intolerance in sedentary, overweight individuals and diabetic patients. The purpose of this study was to determine the impact of an exercise program on arterial stiffness and insulin resistance in a group of patients on hemodialysis. The effect of exercise training on arterial stiffness and insulin resistance in 11 patients who were on chronic hemodialysis was evaluated. Exercise classes of 1-h duration were conducted twice weekly for 3 mo. Arterial stiffness was assessed using the radial artery pressure waveform analysis. Aerobic exercise improved arterial stiffness from 17 +/- 3 u at baseline to 12.2 +/- 3 u at the end of the intervention (P = 0.01). After 1 mo of detraining, arterial stiffness reverted to pre-exercise levels (17.3 +/- 3 u). Pulse pressure paralleled arterial stiffness changes, and the correlation between them was statistically significant (r = 0.725, P = 0.012). Insulin resistance was calculated using the homeostatic model assessment formula. Exercise at the intensity and duration used in our study had no impact on insulin resistance (P = 0.38). These findings suggest that 3 mo of aerobic exercise training improves arterial stiffness, an independent risk factor for cardiovascular mortality in patients who are on hemodialysis, and has no impact on insulin resistance. The beneficial effect on arterial stiffness dissipates within 1 mo of detraining. To obtain therapeutic benefits, an exercise program for patients who are maintained on hemodialysis should be designed to promote regular long term exercise, >3 h/wk.

Extracorporeal management of valproic acid overdose: a large regional experience.

BACKGROUND: Valproic acid intoxication is common in North America. Although extra-corporeal therapy has been proposed as beneficial in managing significant exposures, evidence to support its use is limited to isolated case reports. A systematic review has not been performed. METHODS: All cases of valproic acid overdose in Ontario, Canada, reported to the Hospital for Sick Children Poison Information Centre (PIC) between January 1st and July 31st 2002 were reviewed. Patients with valproic acid levels > 100 microg/mL were divided into two groups: those treated with and without extra-corporeal therapy. All hospital-measured valproic acid levels and additional clinical information including elimination half-life and clearance were obtained for patients treated with extra-corporeal therapy. RESULTS: There were 28,362 calls to the PIC, of which 139 related to valproic acid poisoning. Thirty-two patients had peak levels > 100 microg/mL. 26 patients were managed conservatively and 6 with extra-corporeal therapy. Survival was 100% in both groups. Patients who received extra-corporeal therapy had higher peak levels (p=0.005), were more frequently treated with charcoal (P=0.006), required intensive care admission (P=0.019), intubation (P<0.001), and vasopressors (P=0.004). Valproic acid elimination was enhanced about tenfold through extra-corporeal methods. Complications included tonic-clonic seizures in 1 patient who received hemodialysis, and thrombocytopenia in 1 patient who underwent hemoperfusion. CONCLUSION: Hemodialysis and hemoperfusion are safe, effective adjuncts in the management of serious valproic acid intoxication and should be considered for patients with hemodynamic or neurological instability. Further study is needed to determine whether hemodialysis alone versus combined hemodialysis-hemoperfusion is more effective for this condition.