EditorialRoman-Ulrich Müller received funding from the Ministry of Science North Rhine-Westphalia (Nachwuchsgruppen.NRW 2015–2021), the Marga and Walter Boll Foundation, the PKD Foundation and the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) under Germany’s Excellence Strategy—CECAD, EXC 2030–390661388 as well as DFG MU 3629/6-1 and DFG DI 1501/9

Castle, EM

Greenwood, S

Müller, R-U

Brunel University Research Archive

Citation: Castle, E.M.; Greenwood,S.A.; Müller, R.-U. The Importance ofLifestyle Interventions in thePrevention and Treatment of ChronicKidney Disease. Kidney Dial. 2023, 3,192–195. https://doi.org/10.3390/kidneydial3020017Received: 30 March 2023Accepted: 3 April 2023Published: 10 April 2023Copyright: © 2023 by the authors.Licensee MDPI, Basel, Switzerland.This article is an open access articledistributed under the terms andconditions of the Creative CommonsAttribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).EditorialThe Importance of Lifestyle Interventions in the Prevention andTreatment of Chronic Kidney DiseaseEllen M. Castle 1,* , Sharlene A. Greenwood 2 and Roman-Ulrich Müller 31 Physiotherapy Division, Department of Health Sciences, College of Health, Medicine and Life Sciences,Brunel University London, Uxbridge UB8 3PH, UK2 King’s College Hospital NHS Foundation Trust, Therapies Department, London SE5 9RS, UK;sharlene.greenwood@nhs.net3 Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine andUniversity Hospital Cologne, University of Cologne, 50937 Cologne, Germany* Correspondence: ellen.castle@brunel.ac.ukChronic kidney disease (CKD) is a global health problem, with a prevalence of approxi-mately 13.4% worldwide [1]. Not only is CKD an independent risk factor for Cardiovasculardisease (CVD) [2], it is associated with global mortality and morbidity [3]. Whilst the de-tection and treatment of CKD has improved over recent years, there is a strong need forpreventative care [3]. Over the last few decades, strategies to prevent and treat CKD havelargely focused on pharmacological interventions. However, while this approach hasprovided answers for individual disease settings, the general problem of CKD remains.Non-pharmacological treatments, such as Lifestyle interventions (including dietary rec-ommendations and physical exercise) have been shown to harbour potential for beneficialeffects on kidney health and the resulting co-morbidities [4]. The aim of the Special Issueon “Lifestyle interventions in Kidney Health and Disease” was to provide an overviewon the current knowledge in this field and an outlook towards new research questions.Increasing awareness of lifestyle interventions and creating a setting in which these can beefficiently studied in clinical trials could facilitate future implementation into clinical prac-tice and improvement in outcomes for people living with CKD. This Special Issue included14 peer-reviewed publications reviewing dietary, exercise, and other non-pharmacologicalinterventions in people living with CKD. The work received a lot of attention, as indicatedby three publications being among the top read publications in Kidney & Dialysis in Novem-ber 2022 (https://www.mdpi.com/journal/kidneydial/announcements/4717 accessed on10 March 2023). The key messages from this Special Issue will be summarised below.In ADPKD, animal experiments have shown potential of ketogenic dietary interven-tions ameliorating disease progression [5] and first data in humans point towards potentialtranslatability of this approach [6,7]. In this Special Issue, Bruen et al. [8] provide a firstinsight into a potential tailored dietary intervention that may enable the implementation ofketogenic dietary interventions in real life in the future. This aspect is complemented byrecent evidence on the role of weight reduction in ADPKD. Steele and Nowak [9] facilitatefurther exploration by providing an overview of available data, adding insight into poten-tial mechanisms, and offering suggestions for future research. Ramos et al. [10] explorethe evidence regarding the pathophysiology, assessment and treatment of constipation inpeople living with CKD.Metabolic abnormalities associated with CKD including inflammation, dyslipidaemia,and oxidative stress, and are considered major factors contributing to disease progressionand cardiovascular comorbidity. The review by Ertuglu and Ikizler [11] provides a summaryof the current knowledge regarding how diet and exercise may impact on metabolicendpoints in CKD and suggests future interventions that may improve CKD-associatedoutcomes. The commentary by Artemis Simopoulos [12] extends on these thoughts byKidney Dial. 2023, 3, 192–195. https://doi.org/10.3390/kidneydial3020017 https://www.mdpi.com/journal/kidneydialKidney Dial. 2023, 3 193elaborating on the role of healthy dietary patterns in preventing inflammation. Such dietarypatterns, including DASH- and Mediterranean diets, may become important to preventloss of kidney function and further research is warranted.Physical activity and exercise are recommended for people across all stages of CKD [13,14].To facilitate tailored exercise interventions, the correct assessment tools are required. In thisSpecial Issue, Koufaki [15] suggests physical function outcomes that are key for assessmentand implementation into clinical practice for people living with CKD. There is a growingneed and interest for patient-reported outcomes, such as the Participant’s ActivationMeasure (PAM) [16]. Lightfoot et al. [17] provide a review of patient activation and self-management, their interactions, and the importance of these concepts for self-managementinterventions for people living with CKD.Frailty is an emerging area of research in CKD [18]. Mayes et al. [19] provide a reviewof the evidence addressing the assessment of frailty in people living with CKD, and thenon-pharmacological management strategies to address frailty.A recent systematic review and practice guideline suggests exercise in pre-dialysiscandidates may contribute to improvements in blood pressure, physical function andcapacity, functional limitations, and health-related quality of life [14]. Davies et al. [20]summarize and explore the evidence regarding exercising training and delaying kidneyfunction and decline in individuals with CKD who are non-dialysis dependant. Thepathophysiology, potential risk factors, how exercise may play a role in kidney function,and the need for future research are presented [20]. However, the authors acknowledge thatthere is no known harm associated with exercise in pre-dialysis candidates, the importanceof individualised exercise prescription and the potential benefits of exercise on other healthoutcomes, such as quality of life [20].Recent evidence regarding intra-dialytic cycling (IDC) has sparked debate withinthe CKD community [21–23]. In this Special Issue, King et al. [24] provide an up-to-datesummary of the evidence reviewing IDC for those receiving haemodialysis (HD) andexplore the concerns and benefits of this treatment approach. The authors urge the renalcommunity to consider IDC not as an individual intervention, but as a component within acomprehensive patient-centred intervention [24].Recent international guidelines for physical activity for people receiving Peritonealdialysis (PD) have been published [13]. Despite the guidelines, and feasibility studiessuggesting exercise can be safe in people receiving PD, there is low uptake [25]. The reviewby Lyasere et al. [25] further explores exercise for people living with PD by reviewing thebenefits and limitations of the current evidence, providing clinician and patient insights,and potential steps for future research.Evidence suggests exercise and access to weight management support should berecommended for people following a kidney transplant [14,26]. Whilst weight gain is asignificant issue for new kidney transplant recipients, there is no recommended interventiondesigned to prevent adverse weight gain from occurring [27]. The systematic review andmeta-analysis by Castle et al. [28] explore the effects of exercise interventions, dietaryinterventions and combined interventions on body weight and body mass index in peoplefollowing a kidney transplant.Behavioural change techniques are recommended to facilitate physical activity anddietary interventions [29]. In this Special Issue, Leunis et al. [30] explore physical activitybehaviour in solid organ transplant recipients. The authors draw on the Behaviour ChangeWheel [31] to propose physical activity behaviour change interventions for solid organtransplant candidates [30].The perspective statement contributed by Tess Harris [32] provides the crucial patientperspective and clearly underlines the lack of lifestyle counselling in routine clinical care.This shortcoming, together with a lack of focus on patient-relevant outcomes, and the needfor tools measuring these outcomes, will be topics requiring special attention in the future.Kidney Dial. 2023, 3 194ConclusionsLifestyle interventions to optimise diet, physical activity, exercise, and non-pharmacologicalinterventions are crucial in the prevention and treatment of CKD. The challenge remains inhow to deliver these potential kidney-specific solutions without a trained workforce in place.Novel ways to implement lifestyle interventions at scale, and pragmatically deliver them inroutine clinical practice, should be the focus of further research and implementation projects.This will require coherent stakeholder engagement (e.g., patients, healthcare providers,researchers, and policy-makers) and a commitment from research funding schemes tosupport real-world implementation studies in this field.Funding: Roman-Ulrich Müller received funding from the Ministry of Science North Rhine-Westphalia(Nachwuchsgruppen.NRW 2015–2021), the Marga and Walter Boll Foundation, the PKD Foundationand the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) under Germany’sExcellence Strategy—CECAD, EXC 2030–390661388 as well as DFG MU 3629/6-1 and DFG DI 1501/9.Conflicts of Interest: The Dept. II of Internal Medicine (University Hospital Cologne) receivedresearch funding from Otsuka Pharmaceuticals and Thermo Fisher Scientific. RUM is member of thescientific advisory board of Santa Barbara Nutrients. There are no other conflicts of interest.References1. Lv, J.-C.; Zhang, L.-X. Prevalence and Disease Burden of Chronic Kidney Disease; Springer: Singapore, 2019; Volume 1165. [CrossRef]2. Sarnak, M.J.; Levey, A.S.; Schoolwerth, A.C.; Coresh, J.; Culleton, B.; Hamm, L.L.; McCullough, P.A.; Kasiske, B.L.; Kelepouris, E.;Klag, M.J.; et al. Kidney disease as a risk factor for development of cardiovascular disease a statement from the American HeartAssociation Councils on kidney in cardiovascular disease, high blood pressure research, clinical cardiology, and epidemiologyand prevention. Circulation 2003, 108, 2154–2169. [CrossRef] [PubMed]3. GBD Chronic Kidney Disease Collaboration. Global, regional, and national burden of chronic kidney disease, 1990–2017: Asystematic analysis for the Global Burden of Disease Study 2017. Lancet 2020, 395, 709–733. [CrossRef] [PubMed]4. Estruch, R.; Ros, E.; Salas-Salvadó, J.; Covas, M.-I.; Corella, D.; Arós, F.; Gómez-Gracia, E.; Ruiz-Gutiérrez, V.; Fiol, M.;Lapetra, J.; et al. Primary Prevention of Cardiovascular Disease with a Mediterranean Diet Supplemented with Extra-Virgin OliveOil or Nuts. N. Engl. J. Med. 2018, 378, e34. [CrossRef] [PubMed]5. Torres, J.A.; Kruger, S.L.; Broderick, C.; Amarlkhagva, T.; Agrawal, S.; Dodam, J.R.; Mrug, M.; Lyons, L.A.; Weimbs, T. KetosisAmeliorates Renal Cyst Growth in Polycystic Kidney Disease. Cell Metab. 2019, 30, 1007–1023.e5. [CrossRef]6. Strubl, S.; Oehm, S.; Torres, J.A.; Grundmann, F.; Haratani, J.; Decker, M.; Vuong, S.; Kaur Bhandal, A.; Methot, N.;Haynie-Cion, R.; et al. Ketogenic dietary interventions in autosomal dominant polycystic kidney disease—A retrospective caseseries study: First insights into feasibility, safety and effects. Clin. Kidney J. 2022, 15, 1079–1092. [CrossRef]7. Oehm, S.; Steinke, K.; Schmidt, J.; Arjune, S.; Todorova, P.; Lindemann, C.; Wöstmann, F.; Meyer, F.; Siedek, F.; Weimbs, T.; et al.RESET-PKD: A pilot trial on short-term ketogenic interventions in autosomal dominant polycystic kidney disease. Nephrol. Dial.Transplant. 2022, gfac311. [CrossRef] [PubMed]8. Bruen, D.M.; Kingaard, J.J.; Munits, M.; Paimanta, C.S.; Torres, J.A.; Saville, J.; Weimbs, T. Ren.Nu, a Dietary Program forIndividuals with Autosomal-Dominant Polycystic Kidney Disease Implementing a Sustainable, Plant-Focused, Kidney-Safe,Ketogenic Approach with Avoidance of Renal Stressors. Kidney Dial. 2022, 2, 183–203. [CrossRef]9. Steele, C.; Nowak, K. Obesity, Weight Loss, Lifestyle Interventions, and Autosomal Dominant Polycystic Kidney Disease. KidneyDial. 2022, 2, 106–122. [CrossRef]10. Ramos, C.I.; Nerbass, F.B.; Cuppari, L. Constipation in Chronic Kidney Disease: It Is Time to Bridge the Gap. Kidney Dial. 2022, 2,221–233. [CrossRef]11. Ertuglu, L.A.; Ikizler, T.A. Effect of Diet and Exercise on Metabolic Parameters and Health in Moderate to Advanced KidneyDisease. Kidney Dial. 2022, 2, 330–345. [CrossRef]12. Simopoulos, A.P. Dietary Changes and Their Influence in the Development of Kidney Disease. Kidney Dial. 2022, 2, 131–137.[CrossRef]13. Bennett, P.N.; Bohm, C.; Harasemiw, O.; Brown, L.; Gabrys, I.; Jegatheesan, D.; Johnson, D.W.; Lambert, K.; Lightfoot, C.J.;MacRae, J.; et al. Physical activity and exercise in peritoneal dialysis: International Society for Peritoneal Dialysis and the GlobalRenal Exercise Network practice recommendations. Perit. Dial. Int. 2022, 42, 8–24. [CrossRef] [PubMed]14. Baker, L.; March, D.S.; Wilkinson, T.J.; Billany, R.E.; Bishop, N.C.; Castle, E.M.; Chilcot, J.; Davies, M.D.; Graham-Brown, M.P.M.;Greenwood, S.A.; et al. Renal Association Clinical Practice Guideline. Exercise and Lifestyle in Chronic Kidney Disease 2021; The RenalAssociation: Bristol, UK, 2021.15. Koufaki, P. Assessment of Function Limitations in People with Chronic Kidney Disease for Implementation in Clinical Practice.Kidney Dial. 2022, 2, 234–244. [CrossRef]Kidney Dial. 2023, 3 19516. Hibbard, J.H.; Mahoney, E.R.; Stockard, J.; Tusler, M. Development and testing of a short form of the patient activation measure.Health Serv. Res. 2005, 40, 1918–1930. [CrossRef]17. Lightfoot, C.J.; Nair, D.; Bennett, P.N.; Smith, A.C.; Griffin, A.D.; Warren, M.; Wilkinson, T.J. Patient Activation: The Cornerstoneof Effective Self-Management in Chronic Kidney Disease? Kidney Dial. 2022, 2, 91–105. [CrossRef]18. Chowdhury, R.; Peel, N.M.; Krosch, M.; Hubbard, R.E. Frailty and chronic kidney disease: A systematic review. Arch. Gerontol.Geriatr. 2017, 68, 135–142. [CrossRef]19. Mayes, J.; Young, H.M.L.; Blacklock, R.M.; Lightfoot, C.J.; Chilcot, J.; Nixon, A.C. Targeted Non-Pharmacological Interventionsfor People Living with Frailty and Chronic Kidney Disease. Kidney Dial. 2022, 2, 245–261. [CrossRef]20. Davies, M.; Sandoo, A.; Macdonald, J. The Role of Exercise Training in Delaying Kidney Function Decline in Non-Dialysis-Dependent Chronic Kidney Disease. Kidney Dial. 2022, 2, 262–286. [CrossRef]21. Graham-Brown, M.P.M.; March, D.S.; Young, R.; Highton, P.J.; Young, H.M.L.; Churchward, D.R.; Dungey, M.; Stensel, D.J.;Bishop, N.C.; Brunskill, N.J.; et al. A randomized controlled trial to investigate the effects of intra-dialytic cycling on leftventricular mass. Kidney Int. 2021, 99, 1478–1486. [CrossRef]22. Young, H.M.L.; March, D.S.; Highton, P.J.; Graham-Brown, M.; Churchward, D.C.; Grantham, C.; Goodliffe, S.; Jones, W.; Cheung,M.M.; Greenwood, S.A.; et al. Exercise for people living with frailty and receiving haemodialysis: A mixed-methods randomisedcontrolled feasibility study. BMJ Open 2020, 10, e041227. [CrossRef]23. Greenwood, S.A.; Koufaki, P.; Macdonald, J.H.; Bulley, C.; Bhandari, S.; Burton, J.O.; Dasgupta, I.; Farrington, K.; Ford, I.; Kalra,P.A.; et al. Exercise programme to improve quality of life for patients with end-stage kidney disease receiving haemodialysis: ThePEDAL RCT. Health Technol. Assess. 2021, 25, 1–52. [CrossRef] [PubMed]24. King, A.C.; Wilund, K.R. Next Steps for Intradialytic Cycling Research. Kidney Dial. 2022, 2, 287–295. [CrossRef]25. Iyasere, O.; Young, H.M.L.; Burton, J.O. Peritoneal Dialysis and the Role of Exercise Training Interventions. Kidney Dial. 2022,2, 57–67. [CrossRef]26. Wilkinson, T.J.; Bishop, N.C.; Billany, R.E.; Lightfoot, C.J.; Castle, E.M.; Smith, A.C.; Greenwood, S.A. The effect of exercisetraining interventions in adult kidney transplant recipients: A systematic review and meta-analysis of randomised control trials.Phys. Ther. Rev. 2022, 27, 114–134. [CrossRef]27. Castle, E.M.; Greenwood, J.; Chilcot, J.; Greenwood, S.A. Usability and experience testing to refine an online intervention toprevent weight gain in new kidney transplant recipients. Br. J. Health Psychol. 2020, 26, 232–255. [CrossRef]28. Castle, E.M.; McBride, E.; Greenwood, J.; Bramham, K.; Chilcot, J.; Greenwood, S.A. Do Exercise, Physical Activity, Dietetic,or Combined Interventions Improve Body Weight in New Kidney Transplant Recipients? A Narrative Systematic Review andMeta-Analysis. Kidney Dial. 2021, 1, 100–120. [CrossRef]29. Michie, S.; Ashford, S.; Sniehotta, F.F.; Dombrowski, S.U.; Bishop, A.; French, D.P. A refined taxonomy of behaviour changetechniques to help people change their physical activity and healthy eating behaviours: The CALO-RE taxonomy. Psychol. Health2011, 26, 1479–1498. [CrossRef]30. Leunis, S.; Vandecruys, M.; Cornelissen, V.; Van Craenenbroeck, A.H.; De Geest, S.; Monbaliu, D.; De Smet, S. Physical ActivityBehaviour in Solid Organ Transplant Recipients: Proposal of Theory-Driven Physical Activity Interventions. Kidney Dial. 2022, 2,298–329. [CrossRef]31. Michie, S.; Atkins, L.; West, R. The Behaviour Change Wheel. A Guide to Designing Interventions; Silverback Publishing: Sutton,UK, 2014.32. Harris, T. Lifestyle Interventions in Improving Health Outcomes and Enabling People to Live Well with Kidney Disease. KidneyDial. 2022, 2, 204–208. [CrossRef]Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individualauthor(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury topeople or property resulting from any ideas, methods, instructions or products referred to in the content.

The importance of lifestyle interventions in the prevention and treatment of Chronic Kidney Disease

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The importance of lifestyle interventions in the prevention and treatment of Chronic Kidney Disease

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