Renal rehabilitation services in the UK: protocol for the British Renal Society Rehabilitation Network survey of practice and perspectives

This protocol describes a planned survey of current rehabilitation provision for renal patients across the UK. Rehabilitation, defined as ‘a set of measures that assist individuals who experience, or are likely to experience, disability to achieve and maintain optimal functioning in interaction with their environment’ (World Health Organization, 2011), is gaining increasing recognition as a key component with the management of CKD. [Take from introduction

Targeted Non-Pharmacological Interventions for People Living with Frailty and Chronic Kidney Disease

Frailty is highly prevalent within people living with chronic kidney disease (CKD) and is associated with the increased risk of falls, hospitalisation, and mortality. Alongside this, individuals with CKD report a high incidence of depression and reduced quality of life. The identification of frailty within nephrology clinics is needed to establish comprehensive management plans to improve clinical outcomes and quality of life for people with CKD. Current research exploring the role of non-pharmacological management has primarily focussed on exercise and physical activity interventions in the frail CKD population. However, there is a growing evidence base and interest in this area. This review provides an up-to-date overview of the literature into frailty assessment in CKD and subsequent non-pharmacological treatment approaches

Standardising the measurement of physical activity in people receiving haemodialysis: considerations for research and practice.

BACKGROUND:Physical activity (PA) is exceptionally low amongst the haemodialysis (HD) population, and physical inactivity is a powerful predictor of mortality, making it a prime focus for intervention. Objective measurement of PA using accelerometers is increasing, but standard reporting guidelines essential to effectively evaluate, compare and synthesise the effects of PA interventions are lacking. This study aims to (i) determine the measurement and processing guidance required to ensure representative PA data amongst a diverse HD population, and; (ii) to assess adherence to PA monitor wear amongst HD patients. METHODS:Clinically stable HD patients from the UK and China wore a SenseWear Armband accelerometer for 7 days. Step count between days (HD, Weekday, Weekend) were compared using repeated measures ANCOVA. Intraclass correlation coefficients (ICCs) determined reliability (≥0.80 acceptable). Spearman-Brown prophecy formula, in conjunction with a priori ≥  80% sample size retention, identified the minimum number of days required for representative PA data. RESULTS:Seventy-seven patients (64% men, mean ± SD age 56 ± 14 years, median (interquartile range) time on HD 40 (19-72) months, 40% Chinese, 60% British) participated. Participants took fewer steps on HD days compared with non-HD weekdays and weekend days (3402 [95% CI 2665-4140], 4914 [95% CI 3940-5887], 4633 [95% CI 3558-5707] steps/day, respectively, p < 0.001). PA on HD days were less variable than non-HD days, (ICC 0.723-0.839 versus 0.559-0.611) with ≥ 1 HD day and ≥  3 non-HD days required to provide representative data. Using these criteria, the most stringent wear-time retaining ≥ 80% of the sample was ≥7 h. CONCLUSIONS:At group level, a wear-time of ≥7 h on ≥1HD day and ≥ 3 non-HD days is required to provide reliable PA data whilst retaining an acceptable sample size. PA is low across both HD and non- HD days and future research should focus on interventions designed to increase physical activity in both the intra and interdialytic period

Associations between frailty trajectories and cardiovascular, renal, and mortality outcomes in chronic kidney disease

Background Frailty is characterized by the loss of biological reserves and vulnerability to adverse outcomes. In individuals with chronic kidney disease (CKD), numerous pathophysiological factors may be responsible for frailty development including inflammation, physical inactivity, reduced energy intake, and metabolic acidosis. Given that both CKD and frailty incur a significant healthcare burden, it is important to understand the relationship of CKD and frailty in real-world routine clinical practice, and how simple frailty assessment methods (e.g. frailty indexes) may be useful. We investigated the risk of frailty development in CKD and the impact of frailty status on mortality and end-stage kidney disease (ESKD). Methods A retrospective cohort study using primary care records from the Clinical Practice Research Datalink linked to Hospital Episode Statistics and the UK Office for National Statistics was undertaken in 819 893 participants aged ≥40 years, of which 140 674 had CKD. Frailty was defined using an electronic frailty index, generated electronically from primary care records. Cox proportional hazard and flexible parametric survival models were used to investigate the risk of developing frailty and the effect of frailty on risk of all-cause and cardiovascular mortality, and ESKD. Results The mean age of those with CKD was 77.5 (SD 9.7) years [61.0 (SD 12.1) years in no-CKD group]; 62.0% of the CKD group were female (compared with 53.3% in no-CKD group). The mean estimated glomerular filtration rate of those with CKD was 46.1 (SD 9.9) mL/min/1.73 m2. The majority of those with CKD (75.3%) were frail [vs. 45.4% in those without CKD (no-CKD)]. Over 3 years (median), 69.5% of those with CKD developed frailty. Compared with no-CKD, those with CKD had increased rates of developing mild (hazard ratio: 1.02; 95% confidence interval: 1.01–1.04), moderate (1.30; 1.26–1.34), and severe (1.50; 1.37–1.65) frailty. Mild (1.22; 1.19–1.24), moderate (1.60; 1.56–1.63), and severe (2.16; 2.11–2.22) frailty was associated with increased rates of all-cause and cardiovascular-related mortality (mild 1.35; 1.31–1.39; moderate 1.96; 1.90–2.02; and severe 2.91; 2.81–3.02). All stages of frailty significantly increased ESKD rates. Conclusions Frailty is highly prevalent and associated with adverse outcomes in people with CKD, including mortality and risk of ESKD. Preventative interventions should be initiated to mitigate the development of frailty. The use of a simple frailty index, generated electronically from health records, can predict outcomes and may aid prioritization for management of people with frailty.</p

A cost-effective analysis of the CYCLE-HD randomized controlled trial

Introduction: No formal cost-effectiveness analysis has been performed for programs of cycling exercise during dialysis (intradialytic cycling [IDC]). The objective of this analysis is to determine the effect of a 6-month program of IDC on health care costs. Methods: This is a retrospective formal cost-effectiveness analysis of adult participants with end-stage kidney disease undertaking in-center maintenance hemodialysis enrolled in the CYCLE-HD trial. Data on hospital utilization, primary care consultations, and prescribed medications were extracted from medical records for the 6 months before, during, and after a 6-month program of thrice-weekly IDC. The cost-effectiveness analysis was conducted from a health care service perspective and included the cost of implementing the IDC intervention. The base-case analyses included a 6-month “within trial” analysis and a 12-month “within and posttrial” analysis considering health care utilization and quality of life (QoL) outcomes. Results: Data from the base-case within trial analysis, based on 109 participants (n = 56 control subjects and n = 53 IDC subjects) showed a reduction in health care utilization costs between groups, favoring the IDC group, and a 73% chance of IDC being cost-effective compared with control subjects at a willingness to pay of £20,000 and £30,000 per quality-adjusted life year (QALY) gained. When QoL data points were extrapolated forward to 12 months, the probability of IDC being cost-effective was 93% and 94% at £20,000 and £30,000 per QALY gained. Sensitivity analysis broadly confirms these findings. Conclusion: A 6-month program of IDC is cost-effective and the implementation of these programs nationally should be a priority

Circulating endotoxin and inflammation: associations with fitness, physical activity and the effect of a six-month programme of cycling exercise during haemodialysis

Background: Intradialytic cycling (IDC) may provide cardiovascular benefit to individuals receiving haemodialysis, but the exact mechanism behind these improvements remains unclear. The primary aim of this study was to investigate the effect of a six-month programme of IDC on circulating endotoxin (secondary analysis from the CYCLE-HD trial). Secondary aims were to investigate changes in circulating cytokines (IL-6, IL-10, TNF-α, CRP and IL6/IL-10), and their associations with physical activity, fitness and cardiovascular outcomes. Methods: Participants were randomised to either a six-month programme of IDC (thrice weekly, moderate intensity cycling at RPE 12-14) in addition to usual care (n=46), or usual care only (control group; n=46). Outcome measures were obtained at baseline and then again at six months. Results: There was no significant (P=0.137) difference in circulating endotoxin between groups at 6-months (IDC group: 0.34±0.08 EU/mL; control group: 0.37±0.07 EU/mL). There were no significant between group difference in any circulating cytokine following the 6-month programme of IDC. Higher levels of physical activity and fitness were associated with lower levels of endotoxin, IL-6, CRP, and IL-6/IL-10. Conclusions: Our data show no change in circulating endotoxin or cytokines following a 6-month programme of IDC. However, higher levels of physical activity outside of haemodialysis were associated with lower levels of inflammation

A randomized controlled trial to investigate the effects of intra-dialytic cycling on left ventricular mass

Cardiovascular disease is the leading cause of death for patients receiving hemodialysis. Since exercise mitigates many risk factors which drive cardiovascular disease for these patients, we assessed effects of a program of intra-dialytic cycling on left ventricular mass and other prognostically relevant measures of cardiovascular disease as evaluated by cardiac MRI (the CYCLE-HD trial). This was a prospective, open-label, single-blinded cluster-randomized controlled trial powered to detect a 15g difference in left ventricular mass measured between patients undergoing a six-month program of intra-dialytic cycling (exercise group) and patients continuing usual care (control group). Pre-specified secondary outcomes included measures of myocardial fibrosis, aortic stiffness, physical functioning, quality of life and ventricular arrhythmias. Outcomes were analyzed as intention-to-treat according to a pre-specified statistical analysis plan. Initially, 130 individuals were recruited and completed baseline assessments (65 each group). Ultimately, 101 patients completed the trial protocol (50 control group and 51 exercise group). The six-month program of intra-dialytic cycling resulted in a significant reduction in left ventricular mass between groups (-11.1g; 95% confidence interval -15.79, -6.43), which remained significant on sensitivity analysis (missing data imputed) (-9.92g; 14.68, -5.16). There were significant reductions in both native T1 mapping and aortic pulse wave velocity between groups favoring the intervention. There was no increase in either ventricular ectopic beats or complex ventricular arrhythmias as a result of exercise with no significant effect on physical function or quality of life. Thus, a six-month program of intradialytic cycling reduces left ventricular mass and is safe, deliverable and well tolerated

Circulating endotoxin and inflammation: associations with fitness, physical activity and the effect of a six-month programme of cycling exercise during haemodialysis

BackgroundIntradialytic cycling (IDC) may provide cardiovascular benefit to individuals receiving haemodialysis, but the exact mechanism behind these improvements remains unclear. The primary aim of this study was to investigate the effect of a six-month programme of IDC on circulating endotoxin (secondary analysis from the CYCLE-HD trial). Secondary aims were to investigate changes in circulating cytokines (IL-6, IL-10, TNF-α, CRP and IL6/IL-10), and their associations with physical activity, fitness and cardiovascular outcomes.MethodsParticipants were randomised to either a six-month programme of IDC (thrice weekly, moderate intensity cycling at RPE 12-14) in addition to usual care (n = 46), or usual care only (control group; n = 46). Outcome measures were obtained at baseline and then again at six months.ResultsThere was no significant (P=0.137) difference in circulating endotoxin between groups at 6-months (IDC group: 0.34±0.08 EU/mL; control group: 0.37±0.07 EU/mL). There were no significant between group difference in any circulating cytokine following the 6-month programme of IDC. Higher levels of physical activity and fitness were associated with lower levels of endotoxin, IL-6, CRP, and IL-6/IL-10.ConclusionsOur data show no change in circulating endotoxin or cytokines following a 6-month programme of IDC. However, higher levels of physical activity outside of haemodialysis were associated with lower levels of inflammation.</div

The rapid development of a novel kidney-specific digital intervention for self-management of physical activity and emotional well-being during the COVID-19 pandemic and beyond: Kidney Beam

Letter to the Editor

Impact of physical activity on surrogate markers of cardiovascular disease in the haemodialysis population

Background and hypothesis The haemodialysis population is sedentary with substantial cardiovascular disease risk. In the general population, small increases in daily step count associate with significant reductions in cardiovascular mortality. This study explores the relationship between daily step count and surrogate markers of cardiovascular disease, including left ventricular fraction (LVEF) and native T1 (a marker of diffuse myocardial fibrosis), within the haemodialysis population.  Methods  This was a post-hoc analysis of the association between daily step count and metabolic equivalent of task (MET) and prognostically important cardiac magnetic resonance imaging (CMR) parameters from the CYCLE-HD study (ISRCTN11299707). Unadjusted linear regression and multiple linear regression adjusted for age, body mass index, dialysis vintage, haemoglobin, hypertension and ultrafiltration volume were performed. Significant relationships were explored with natural cubic spline models with four degrees of freedom (five knots).  Results  107 participants were included; 56.3 ± 14.1 years, 79 (73.8%) males. Median daily step count was 2558 (IQR 1054–4352). There were significant associations between: steps and LVEF (β = 0.292; P = 0.009); steps and native T1 (β = -0.245; P = 0.035). Further modelling demonstrated most of the increase in LVEF occurred up to 2,000 steps per day and there was an inverse dose-response relationship between steps and native T1, with the most pronounced reduction in native T1 between ∼2,500 and 6,000 steps per day.  Conclusions  These results suggest an association between daily step count and parameters of cardiovascular health in the haemodialysis population. These findings support the recommendations for encouraging physical activity but they are not the justification. Further research should evaluate whether a simple physical activity intervention improves cardiovascular outcomes in individuals receiving maintenance haemodialysis.</p