Exercício aeróbico baseado no primeiro limiar ventilatório em pacientes com excesso de peso e doença renal crônica: impacto sobre a capacidade cardiorrespiratória e funcional

INTRODUCTION: Chronic kidney disease (CKD) and obesity are both associated with reduced physical capacity. The potential benefit of aerobic training on physical capacity has been recognized. The exercise intensity can be established using different methods mostly subjective or indirect. Ventilatory threshold (VT) is a direct and objective method that allows prescribing exercise intensity according to individual capacity. OBJECTIVES: To evaluate the impact of aerobic training at VT intensity on cardiopulmonary and functional capacities in CKD patients with excess of body weight. METHODS: Ten CKD patients (eight men, 49.7 ± 10.1 years; BMI 30.4 ± 3.5 kg/m², creatinine clearance 39.4 ± 9.8 mL/min/1.73 m²) underwent training on a treadmill three times per week during 12 weeks. Cardiopulmonary capacity (ergoespirometry), functional capacity and clinical parameters were evaluated. RESULTS: At the end of 12 weeks, VO2PEAK increased by 20%, and the speed at VO2PEAK increased by 16%. The training resulted in improvement in functional capacity tests, such as six-minute walk test (9.2%), two-minute step test (20.3%), arm curl test (16.3%), sit and stand test (35.7%), and time up and go test (15.3%). In addition, a decrease in systolic and diastolic blood pressures was observed despite no change in body weight, sodium intake and antihypertensive medication. CONCLUSION: Aerobic exercise performed at VT intensity improved cardipulmonary and functional capacities of overweight CKD patients. Additional benefit on blood pressure was observed. These results suggest that VT can be effectively applied for prescribing exercise intensity in this particular group of patients.INTRODUÇÃO: O excesso de peso e a doença renal crônica (DRC) estão associados à baixa capacidade cardiorrespiratória (CR) e funcional (CF). Já foi observado que o treinamento aeróbico (TA) melhora a CR e CF. Métodos indiretos e subjetivos são comumente empregados para a prescrição da intensidade do TA. O limiar ventilatório (LV) é um método direto e objetivo que permite prescrever a intensidade do TA de acordo com a capacidade física do paciente. OBJETIVOS: Avaliar o impacto do TA com base na intensidade do LV sobre a CR e CF de pacientes com excesso de peso e portadores de DRC na fase não dialítica. MÉTODOS: Dez pacientes (oito homens; 49 ± 10,1 anos, IMC 30,4 ± 3,5 kg/m² , depuração de creatinina 39,4 ± 9,8 mL/min/1,73m²) foram submetidos à TA 3 vezes por semana durante 12 semanas. CR (ergoespirometria), CF e parâmetros clínicos foram avaliados. RESULTADOS: O TA promoveu aumento de 20% no consumo pico de O2 (VO2PICO), 16% na velocidade alcançada no VO2PICO e melhora em 9,2% na caminhada de seis minutos, 20,3% na marcha estacionária, 35,7% no sentar e levantar, 16,3% na resistência muscular de membro superior e 15,3% no tempo de ir e voltar. A pressão arterial diminuiu sem modificação nos anti-hipertensivos, no peso ou no consumo de sódio. CONCLUSÃO: Os resultados indicam que o TA baseado na intensidade do LV melhora a CR, CF e pressão arterial de pacientes portadores de DRC com excesso de peso. Isso sugere que o TA baseado na intensidade LV é eficaz e pode ser empregado com segurança nesses pacientes.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)Universidade Federal de São Paulo (UNIFESP)UNIFESP Fundação Oswaldo RamosUNIFESP, Fundação Oswaldo RamosSciEL

Impact of training at ventilatory threshold on cardiopulmonary and functional capacity in overweight patients with CKD

BV UNIFESP: Teses e dissertaçõe

Efeito do exercício aeróbico à distância em relação ao presencial sobre os parâmetros cardiorrespiratórios e capacidade funcional de pacientes com doença renal crônica

Introduction: In patients with chronic kidney disease (CKD) the presence of overweight or obesity is associated with several metabolic complications, including worsening renal function. In addition, the association between CKD and excess body fat can lead to aggravation of cardiorespiratory capacity, physical function and quality of life of the patients. Studies show that aerobic training improves several aspects of physical capacity of these patients. Although the incorporation of physical exercise on a CKD standard treatment is a challenge and this is recommended by current guidelines for all stages of disease. Besides, the lack of studies showing real benefits of practical and affordable programs further complicates the implementation of training programs for these patients. Objective: The aim of this study was compare the performance of aerobic exercise performed remotely (home-based) with the conducted in person (center-base) on cardiorespiratory and functional capacity of overweight patients with non- dialysis dependent CKD (stage 3 or 4). Methods: This was a prospective, randomized, interventional, controlled trial of a 24 weeks. Forty sedentary patients were studied (27 men), aged 55.5±8.3 years (mean±SD); BMI of 31.2±4.4 kg/m2 and estimated glomerular filtration rate of 26.9±11.7 mL/min/1.73m2. The patients were randomly assigned to the control group or the exercise group. Those who were assigned to the exercise group could choose to perform the home-based exercise or center-based exercise. The control group was instructed not to perform exercise during the follow-up. The patients from the center-based exercise group performed the aerobic training on a treadmill three times per week during 12 weeks on 9 alternate days at the Psychobiology and Exercise Study Centre under supervision of an exercise physiologist. The patients from the home-based exercise group performed aerobic training at locations nearby their home, backyard, park or street three times per week on alternate days during 12 weeks according to the instructions given by exercise physiologist. The exercised groups were subjected to the same continuous aerobic exercise protocol consisted of three weekly sessions on alternate days, at the intensity of anaerobic threshold lasting 30 minutes. The duration was increased by 10 minutes every four weeks until it reached 50 minutes. Patients underwent assessment of cardiorespiratory fitness, functional capacity tests, the questionnaire of quality of life (SF-36), questionnaire of quality of sleep (Pittsburgh sleep quality index) and routine laboratory tests before, after 12 weeks and after 24 weeks of follow-up. Results: A significant increase (p<0.05) of VO2 peak, speed at anaerobic threshold, VO2 at respiratory compensation point and maximum ventilation was observed after 12 weeks of training in the home-based group, reaching values similar to those obtained in the center-based group . As for the functional testing was observed improvement in 6-minute walk test, time up and go test, step test, sit and stand test and arm curl test was found after 12 weeks of training in the home-based group, achieving values not different from those in the center-based group. In both exercised groups the values achieved in the tests were maintained until the end of 24 weeks. No changes in those parameters were observed in the control group. The benefits observed in cardiorespiratory parameters and functional capacity resulting from the exercise reflected in improved quality of life and sleep. In addition, only in the exercised groups there 10 was a decrease in blood pressure, with no change in antihypertensive medication, sodium intake and body weight. No adverse effects were observed. Conclusion: Home-based aerobic training promoted similar benefits to those found in the center-based group in cardiorespiratory fitness, functional capacity, quality of life and sleep besides reducing blood pressure of overweight patients with CKD. The results of this study indicate that home-based exercise is effective and can be used safely.Introdução e objetivo: Na doença renal crônica (DRC) a presença de sobrepeso ou obesidade está associada a inúmeras complicações metabólicas, inclusive a piora da função renal. Além disso, a associação entre DRC e excesso de gordura corporal pode levar ao agravamento da capacidade cardiorrespiratória, funcional e da qualidade de vida dos pacientes. Estudos mostram que o treinamento aeróbico melhora vários aspectos da capacidade física desses pacientes. Embora a incorporação do exercício físico em um tratamento padrão de DRC seja um desafio, este é recomendado pelas diretrizes atuais para todas as fases da doença. Porém, a escassez de estudos mostrando benefícios reais de programas práticos e acessíveis, dificultam ainda mais a implementação de programas de treinamento para esses pacientes. Portanto, o presente estudo teve como objetivo comparar o desempenho do exercício aeróbico realizado à distância com o realizado presencialmente sobre a capacidade cardiorrespiratória e funcional de pacientes com DRC na fase não dialítica e com excesso de peso corporal. Métodos: Foram estudados 40 pacientes (27 homens) sedentários que se encontravam nos estágios 3 ou 4 da DRC, com idade de 55,5±8,3 anos (média±DP), IMC de 31,2±4,4 kg/m2 e taxa de filtração glomerular estimada de 26,9±11,7 mL/min/1,73m2. Os pacientes foram randomicamente alocados para o grupo controle ou para o grupo exercício. Aqueles que foram designados ao grupo exercício puderam escolher entre realizar o exercício à distância ou presencial. O grupo controle permaneceu sem praticar exercício. O grupo presencial realizou caminhada em esteira rolante e foi monitorado durante todas as sessões, o grupo distância realizou caminhada em domicílio, com acompanhamento realizado por meio de ligações telefônicas semanais e visitas mensais. Os grupos exercitados foram submetidos ao mesmo protocolo de exercício aeróbico contínuo que consistiu de três sessões semanais em dias alternados, na intensidade do LV1 com duração de 30 minutos. A duração foi aumentada em 10 minutos a cada 4 semanas até que se alcançasse 50 minutos. Os pacientes foram submetidos à avaliação da capacidade cardiorrespiratória, a testes de capacidade funcional, ao questionário de qualidade de vida (SF-36), ao questionário de qualidade de sono (PSQI) e à exames laboratoriais de rotina, antes, após 12 semanas e após 24 semanas de seguimento. Resultados: Um aumento significante (p<0,05) no VO2 pico, na velocidade no LV1, no VO2 no LV2 e na ventilação máxima foi observado ao final de 12 semanas de treinamento no grupo distância, alcançando valores semelhantes aos obtidos no grupo presencial. Quanto aos testes funcionais observou-se melhora na caminhada de 6 minutos, ir e voltar, marcha estacionária, sentar e levantar e resistência muscular de membro superior ao final de 12 semanas de treinamento, no grupo distância, com valores que não diferiram dos obtidos no grupo presencial. Em ambos os grupos exercitados os valores alcançados nesses parâmetros se mantiveram ao final das 24 semanas. Nenhuma modificação nesses parâmetros foi encontrada no grupo controle. Os benefícios observados nos parâmetros cardiorrespiratórios e na capacidade funcional decorrentes do exercício refletiram em melhora da qualidade de vida e sono. Além disso, somente nos grupos exercitados foi observado diminuição na pressão arterial, sem que houvesse modificação da medicação anti-hipertensiva, do consumo de sódio e do peso corporal. Nenhum efeito adverso foi observado. Conclusão: O treinamento aeróbico à distância promoveu benefícios semelhantes ao presencial na condição cardiorrespiratória, capacidade funcional, qualidade de vida e sono, além de reduzir a pressão arterial de pacientes obesos com doença renal crônica. Os resultados do presente estudo indicam que o exercício à distância é eficaz e pode ser empregado com segurança.Dados abertos - Sucupira - Teses e dissertações (2013 a 2016

HOME-BASED VS IN CENTER AEROBIC EXERCISE: IMPACT ON CARDIORESPIRATORY (CR) AND FUNCTIONAL CAPACITIES (FC) OF NONDIALYSIS DEPENDENT OVERWEIGHT CKD PATIENTS

We tested the hypothesis that home-based exercise (HE) was similarly effective to the in center exercise (CE) on CR and FC. This is a randomized controlled study that included 35 sedentary patients (23 men; 53±8.1 years, BMI 30.7±4.2 kg/m2, creatinine clearance 30.9±4.2 mL/min; DM 23%). Patients were randomly assigned to HE (n=11), CE (n=12) or control (CO, n=12) groups. CE and HE underwent to an identical exercise program, three times per week during 12 weeks. The CO group remained without practicing exercise during follow up. The CE patients trained on a treadmill while the HE patients were instructed how to perform the training at home and were monitored by phone once a week. The training resulted in increase 20% and 19% in maximal ventilation (p<0.05), 14.5% and 11% in speed of VO2peak (p<0.01), 25.7% and 17.5% in speed of ventilatory threshold (p<0.01) and 20% and 17.2% in speed of respiratory compensation point (p<0.001) only in CE and HE groups respectively. In the exercise groups, improvement in functional capacity tests such as 2-min step (p<0.01), sit-stand (p<0.001) and arm curl (p<0.001) was observed. Blood pressure decreassed only in the exercise groups (p<0.01), in conclusion HE promoted similarly effective that CE and can be effectively applied for this particular group of patients

Impact of home-based aerobic exercise on the physical capacity of overweight patients with chronic kidney disease

Home-based exercise has been shown to provide benefits in terms of physical capacity in the general population, but has been scarcely investigated in patients with chronic kidney disease (CKD).To evaluate the impact of a home-based aerobic training on the cardiopulmonary and functional capacities of overweight non-dialysis-dependent patients with CKD (NDD-CKD).Twenty-nine sedentary patients (55.1 +/- A 11.6 years, BMI = 31.2 +/- A 6.1 kg/m(2), eGFR = 26.9 +/- A 17.4 mL/min/1.73 m(2)) were randomly assigned to a home-based exercise group (n = 14) or to a control group (n = 15) that remained without performing exercise. Aerobic training was performed three times per week for 12 weeks. A cardiopulmonary exercise test, functional capacity and clinical parameters were evaluated.A significant increase, ranging from 8.3 to 17 %, was observed in the cardiopulmonary capacity parameters, such as maximal ventilation (p = 0.005), VO2peak (p = 0.049), ventilatory threshold (p = 0.040) and respiratory compensation point (p < 0.001), of the exercise group. A simultaneous improvement in the functional capacity tests [6-min walk test (p < 0.001), time up and go test (p < 0.001), arm curl test (p < 0.001), sit and stand test (p < 0.001), 2-min step test (p < 0.001) and back scratch test (p = 0.042)] was also found in patients who were submitted to the exercise. Exercised patients experienced a decrease in systolic and diastolic blood pressure, average 10.6 % (p < 0.001) and 9.2 % (p = 0.007), respectively, and a trend toward improved renal function (p = 0.1). No change in any parameter was found in the control group during the follow-up.The home-based aerobic exercise program was feasible, safe and effective for the improvement in the cardiopulmonary and functional capacities of overweight NDD-CKD patients.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)Oswaldo Ramos FoundationCentro de Estudos em Psicobiologia e Exercicio/Associacao de Fundo e Incentivo a PesquisaUniversidade Federal de São Paulo, Div Nephrol, BR-04039000 São Paulo, BrazilUniversidade Federal de São Paulo, Nutr Program, BR-04039000 São Paulo, BrazilUniversidade Federal de São Paulo, Dept Psychobiol, BR-04039000 São Paulo, BrazilUniversidade Federal de São Paulo, Div Nephrol, BR-04039000 São Paulo, BrazilUniversidade Federal de São Paulo, Nutr Program, BR-04039000 São Paulo, BrazilUniversidade Federal de São Paulo, Dept Psychobiol, BR-04039000 São Paulo, BrazilFAPESP: 2009/147860Web of Scienc

IMPACT OF AEROBIC EXERCISE ON VISCERAL FAT OF NONDIALYSIS DEPENDENT OVERWEIGHT CKD PATIENTS: A PILOT STUDY

This is a randomized controlled study that aimed to assess the impact of aerobic exercise on visceral fat of overweight CKD patients. Twenty-six sedentary patients in stages 3–4 of CKD (73% men; 52.3±8.6 years, BMI 30.6±4.3 kg/m2) were included. Patients were assigned to aerobic exercise group (EG; n=13) or control group (CG; n=13). The aerobic training was conducted on a treadmill at the ventilatory threshold three times per week during 12 weeks. The CG patients remained without practicing exercise during follow up. Visceral and subcutaneous fat were assessed by computed tomography, and lean body mass (LBM) by DEXA. At the end of 12 weeks, visceral fat decreased 5% in EG and increased 3% in CG (p=0.02). Waist circumference decreased 1.5% in EG and increased 0.8% in CG (p=0.02). No changes were observed in body weight and subcutaneous fat. LBM tended to increase in EG and decrease in CG (p=0.09). In addition, blood pressure decreased (p<0.01) despite no change in body weight, 24 h urinary sodium and antihypertensive medication. Our results suggest aerobic exercise as an effective approach to reduce visceral fat while maintaining lean body mass in CKD patients

Effect of Aerobic Exercise on Markers of Bone Metabolism of Overweight and Obese Patients With Chronic Kidney Disease

Objective: The aim of the study was to investigate the effect of aerobic exercise on markers of bone metabolism in overweight and obese nondialysis-dependent patients with chronic kidney disease. Methods: This is a post-hoc study with 39 sedentary patients (55.5 +/- 68.3 years, body mass index 31.2 +/- 64.4 kg/m(2), estimated glomerular filtration rate 26.9 +/- 6 11.7 mL/minute) who were randomly assigned to the aerobic exercise group (n = 24) or the control group (n = 15). The aerobic training (walking) was prescribed according to ventilatory threshold and was performed 3 times per week during 24 weeks. Carboxylated and undercarboxylated osteocalcin (GLA and GLU), sclerostin and tartrate-resistant acid phosphatase isoform 5b (TRAP-5b), parathyroid hormone, total alkaline phosphatase (AP), body composition, cardiorespiratory, and functional capacity tests were measured at baseline and after the follow-up. Results: At baseline, carboxylated osteocalcin (GLA) and undercarboxylated osteocalcin (GLU) were inversely correlated with estimated glomerular filtration rate (r = -0.64r = -0.38, respectively). Both osteocalcin fragments were positively correlated with total AP (GLA: r = 0.36GLU: r = 0.53). An inverse correlation was found between GLA and sclerostin with body fat (r = -0.36r = -0.46, respectively). GLU was negatively correlated with markers of muscle mass (r = -0.34). TRAP-5b and sclerostin were inversely correlated with 6-minute walk test and time up and go test, respectively (r = -0.34r = -0.35, respectively). After 24 weeks, all physical capacity parameters increased in the exercise group (P < .001). Except for total AP that increased after 24 weeks in the exercise group (P < 05), no other changes were observed in both groups in relation to the bone metabolism biomarkers investigated. Conclusion(s): In this post-hoc study, the aerobic training used did not promote relevant changes in the bone metabolism markers investigated. (C) 2017 by the National Kidney Foundation, Inc. All rights reserved.Fundação de Amparo a Pesquisa do Estado de São Paulo (FAPESP)Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)Oswaldo Ramos FoundationUniv Fed São Paulo, Nutr Program, São Paulo, BrazilUniv Fed São Paulo, Div Nephrol, Dept Med, São Paulo, BrazilUniv São Paulo, Div Nephrol, Dept Med, São Paulo, BrazilNove de Julho Univ UNINOVE, São Paulo, BrazilUniv Fed São Paulo, Nutr Program, São Paulo, BrazilUniv Fed São Paulo, Div Nephrol, Dept Med, São Paulo, BrazilFAPESP: 2009/14786-0Web of Scienc

In vitro effect of uremic serum on barrier function and inflammation in human colonocytes

ABSTRACT Introduction: In chronic kidney disease (CKD), it has been suggested that alterations within the gut are associated with an inflammatory state and uremic toxicity. Studies suggest that uremia may impair the function of the intestinal barrier via the promotion of increased intestinal permeability. To understand the mechanisms that are involved in intestinal barrier damage in the setting of uremia, we evaluated the in vitro effect of uremic serum on transepithelial electrical resistance (TER), inflammation, and apoptosis in intestinal epithelial cells (T84). Methods: Pools of serum from healthy individuals, patients not on dialysis, and patients on hemodialysis (Pre-HD and Post-HD) were prepared. T84 cells were incubated for 24 h in medium, of which 10% consisted of the pooled serum from each group. After incubation, the TER was measured and the following parameters were determined by flow cytometry: expression of toll-like receptors (TLRs), production of reactive oxygen species (ROS), and apoptosis. The level of IL-6 in the culture supernatant was determined by ELISA. Results: No difference was observed among the groups with respect to TER, apoptosis, and ROS or the expression of TLR-2, TLR-4, and TLR-9. IL-6 secretion was higher (p < 0.001) in cells that were incubated with pre- and post-HD serum. Conclusion: The results that were obtained from this model suggest that uremic serum per se does not seem to impair the integrity of intestinal epithelial cells. The increased IL-6 secretion by cells that were incubated with HD serum suggests a potential effect of uremia in the intestinal inflammatory response