1. CKD and Exercise 中國醫藥大學北港附設醫院 復健科主任 陳信水

2. CKD associated physical dysfunction Muscle wasting Weight loss Excessive fatigue Sexual dysfunction Uremic myopathy Uremic neuropathy

3. Factors leading to poor physical function in CKD Inactivity Functional and structural muscle abnormalities Inflammation Blood flow and anemia

4. History of HD exercise 30 years ago: first introduced. –Exercise training improves abnormal lipid and carbohydrate metabolism in hemodialysis patients. –Trans Am Soc Artif Intern Organs. 1979;25:431-7 Previous study: –The effectiveness of intradialytic leg ergometry exercise for improving sedentary life style and fatigue among patients with chronic kidney disease: A randomized clinical trial –Int J Nurs Stud. 2010 May 25.

5. Exercise is a good advice to HD patients 1979-2005: many studies to HD with exercise benefits. Critical review to commend exercise is a good health to HD. 2005 to now :exercises are not provacated to suggest to HD patients. Why?

6. Uncontrolled triads

7. Nonrandomized controlled trials

8. Randomized controlled trials

10. The effects of exercise Muscle structure and function Cardiac function Blood pressure and other cardiovascular risk factors. Glycemic control and insulin resistance HD efficiency Psychological adaptation, quality of life and nutrition

11. The assessment of exercise capacity Exercise tolerance tests Functional capacity tests Neuromuscular function tests Muscle composition and structure.

12. Aerobic exercise training during hemodialysis increased physical functioning, reduced blood pressure levels, and improved the control of anemia and quality of life in patients with end-stage renal disease.

13. Practical methods for applying exercise therapy Recommendations –Age over 65y/o or 45-64y/o with chronic diseases can be apply to ACKD patients. Circulation 2007;116:1094-1105 Exercise type: aerobic, resistance and flexibility activities. –Aerobic:30 min, mod intensity, 5 days/week –Resistance: major muscle group, 2 times/week –Flexibility activities: all days that A and R performed.

14. Exercise protocols Intra-dialysis exercise Home exercise

15. Adaptation to exercise training in hemodialysis Physical adaptations to exercise training Functional adaptations to exercise training Psychologic adaptations to exercise training

16. Physical adaptations to exercise training The cardiorespiratory system and aerobic capacity. Cardiac functioning. Muscle architecture and neuromuscular control. Components of metabolic syndrome. Dialysis adequacy.

17. Functional adaptations to exercise training Muscular strength Functional performance Disability Depression Quality of life Psychological adaptations to exercise training

18. Limitation on exercise therapy Exercise protocols currently available have often been developed for research. The dropout rate is high. Clear contraindication for exercise are excluded most of HD patients. Age-relative limitation

19. Exercise is contraindicated in CKD Patients with a systolic blood pressure > 200 mm Hg or a diastolic blood pressure > 110 mm Hg. electrolyte abnormalities. recent myocardial infarction. recent changes in the electrocardiogram. The American College of Sports Medicine (ACSM)

20. Conclusion No large randomized controlled trials evaluating the survival benefits of exercise. Frail and incapacitated patients are mostly need physical rehabilitation as a part of there clinical care Exercise are likely to be significant gains for healthcare system by reducing the collateral costs of CKD patient who was deconditioning.